raw_content:
Narrative:
The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. LPA Rosas and AGPA Barnes-Woodard conducted interviews with clients and facility staff. Facility denied the allegations of that minors are being sexually abused while in care. LPA Rosas reviewed staff training that is tracked in Relias digital system. LPA Rosas reviewed special incident reports submitted to the Department. LPA Rosas was not able to find evidence to prove that the alleged violations occurred based on the lack of details provided. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegation of Neglect/Lack of Supervision is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On October 20, 2022, at 10:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted inspection and conducted interviews on July 25, 2021. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated October 20, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Neglect/Lack of Supervision allegations that minors are being sexually abused while in care and minor sustained injuries while in care. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOMEFACILITY NUMBER: VISIT DATE: 10/20/2022

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

met_with: Staff#1 (S1)


state: CA

facility_name: NEW WAY GROUP HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. LPA Rosas and AGPA Barnes-Woodard conducted interviews with clients and facility staff that provided information on staff schedules, and care and supervision for clients. Facility denied the allegations of facility staff sharing drugs, and tobacco. It was reported by the facility and clients that staff does not smoke in the facility. At times clients do bring contraband of alcohol, marijuana or vape pens but staff confiscates it. Based on the interviews there was not enough information to identify which staff was alleged or resident. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegation of Neglect/Lack of Supervision is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On October 20, 2022, at 10:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted inspection and conducted interviews on June 27, 2021. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated October 20, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Neglect/Lack of Supervision allegation that facility staff are sharing drugs and tobacco with residents. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOMEFACILITY NUMBER: VISIT DATE: 10/20/2022

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


raw_content:
Narrative:
On February 22, 2022, facility reported a Special Incident Report (SIR) noting that Client#1 (C1) was verbally and physically attacked by Client#2 (C2) despite staff redirection. C2 began to get verbally aggressive towards C1 slapped C1 face. Facility staff was able to intervene to prevent further assault. Staff then went on a drive with C1 and was able to de-escalate resident. C1 was able to process with the other staff as well and return to baseline. On March 2, 2022, C3 made and inappropriate comment towards roommate (C1). Facility staff counsel C2 about making inappropriate comments it would make others feel uneasy and uncomfortable. On 04/01/2022, C1 was moved to New Way 2. Facility policy does not allow residents to attack each other verbally or aggressively. They always supervise residents and redirect residents. LPA Rosas ensured to thoroughly review the records of the primary active staff. The facility provided evidence of staff training transcripts stored in RELIAS Training Program digital system with a schedule to complete Hours for new hires and ongoing training for various topics including Trauma Informed, and Medication. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for clients in placement. LPA Rosas conducted interviews with clients, and facility staff that provided information on facility care and supervision for residents. There was not enough evidence and information to corroborate the allegations of Neglect and lack of supervision. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegation of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On January 19, 2023, at 12:30pm, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. On 02/15/2022, Licensing Program Analysts (LPA's) Enrique Hernandez and Nancy O'Connel conducted an inspection and conducted interviews. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 01/19/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegation that facility did not prevent minors from threatening another minor in care. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOMEFACILITY NUMBER: VISIT DATE: 01/19/2023

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


raw_content:
Narrative:
On 06/13/2021, the Department received Special Incident Report (SIR) Child#1 (C1) was provoking Child#2 (C2) through the morning despite facility staff intervening multiple times and encouraging C1 to use cooking skills. C1 went to the kitchen and threw a plastic bowl at C2 and retaliation C2 grabbed a wooden spatula and threw it at C1 and striking them in the head. C1 was taken to Urgent Care due to small cut on the head and eye pain. Urgent Care applied four staples versus adhesive glue to C1 head wound due to the position of the injury. On 09/07/2021, LPA Rosas inspected the facility and saw the eye and head injury on C1 healed. C1 expressed not having pain or discomfort. Interviews revealed that residents were counseled, and staff was present during the incident, but the attack happen quickly. The resident was given 1:1 to supervise and shadow C1 due to behavior and abilities. There was not enough evidence and information to corroborate the allegations of Neglect and lack of supervision. On 07/31/21, the Department received SIR reported that when staff is not looking, they call him names like "dog or puppy" and flip him off. C1 punched the window by accident due to Tourette syndrome disorder and did not mean to break the window. C1 did not disclose what resident was doing the name calling. Facility reported not allowing residents to abuse each other verbally or physically. LPA Rosas reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the clients in placement. On August 2, 2021, the Oxnard Police Department arrived at the facility due to an anonymous to report that C1 was being bullied and threatened with knives. The Police Department interview residents in place and inspected the facility and found no suspicious activity and left the facility. On 09/08/2021, inspected facility and found all knives and sharps kept under double locks in the staff office closet. The facility always has two to three staff to supervise clients in placement. Confidential interviews indicated that restraints are conducted when clients in care pose imminent danger to self and others, staff must be SAFE trained, and two or more staff must conduct the restraint. The facility also used variety of redirecting techniques to calm clients during crisis. LPA Rosas conducted interviews with client, pertinent parties, and facility staff regarding to incident on 07/31/2021. There were no witnesses identified to corroborate the allegation. Report continues LIC-9099C Page 1 out of On 06/10/2021, Facility submitted updated reporting requirements updated policy. LPA Rosas reviewed reporting requirements with facility. Facility was able to provide Special Incident Reports and Law Enforcement Contact Reports. Special incident reports are submitted to the Community Care Licensing Department (CCLD), Social Worker and other pertinent parties related to the incident. There was not enough evidence and witnesses identified to corroborate the allegation. On 8/31/ 21, CCLD received an allegation reporting that on 08/29/21, S1 physically restrained C1 causing injuries to C1's neck area and possible rib fracture. Licensing Program Analyst (LPA), Regina Martin investigated the complaint allegation and based on information obtained, the preponderance of the evidence standard has been met, the allegation of physical abuse was substantiated. The allegation has already been investigated and completed by the Department and no further information obtained. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility. Page 3 of 3

Investigation Findings:
13On January 19, 2023, at 12:30pm, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 1 for the purpose of concluding the investigation on the above allegations and to deliver the finding. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 01/19/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegations Minor was physically injured by other minor in group home, minor not accorded dignity in personal relationships, and Staff did not report incident which threatened the physical or emotional health or safety of minor. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C Page 1 out of UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOMEFACILITY NUMBER: VISIT DATE: 01/19/2023

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


facility_name: NEW WAY GROUP HOME 2

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

raw_content:
Narrative:
On Wednesday, May 18th, 2022, at approximately 5:30pm, Client#1 (C1) was walking around the house in frustration and anger as Staff#2 (S2) was asking if C1 needed to talk to his therapist or take a walk. C1 continued to dwell on the incident that happened earlier in the day and was disrespectful and rude towards S2 and Staff#3 (S3) and Staff#4 (S4). S4 offer to talk about the incident and C1 walked out of the facility and over to the office window and began kicking. C1 was able to kick the window in and started to make verbal threats towards staff. S2 used proximity control to keep C1 from getting near the broken window. C1 then walked around to the side of the house and began kicking the fence. C1 broke off a few wooden pieces that were connected to the fence. C1 was able to apprehend the broken wood pieces. In addition, C1 began to hit the electrical box from the facility and removed the lock from the electrical box. S2 was shadowing C1 to try to redirect and to de-escalate C1. C1 then turned towards the neighbor's fence door and began kicking. C1 was able to break the side neighbor's door. S2 used verbal redirection and body positioning to keep C1 from destroying more property on the neighbor's fence. The nearby neighbors came outside of their home and were viewing the incident. C1 began to say began to say some very inappropriate words and threats to the standby neighbors. S3 contacted non-emergency numbers and Oxnard Police Department. C1 then began to run towards the neighbor and crossing the street with ongoing traffic. At 6:06pm S2 conducted one-person SAFE bear hug restrain to stop C1 from harming himself and others. At 6:30pm Oxnard Police Department arrived and detained minor C1. Oxnard Police Department notified S2, S3 that C1 would be placed on a 72-hr hold/5150 at St. John's Regional Medical Center stating he was threatening the staff, children and destroying property. Based on witness, and video footage S2 conducted inappropriate restrain hold to C1 to prevent from harming himself and others. LPA Rosas ensured to thoroughly review the records of the primary active staff. The facility provided evidence of staff training transcripts stored in RELIAS Training Program digital system with a schedule to complete Hours for new hires and ongoing training for various topics including Trauma Informed, and CSEC training. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for clients in placement. In addition, LPA reviewed C1 file record that include Admission Agreement, Inventory of Personal Belongings and cash resources, Dental and Medical forms, Consent Forms, Psychotropic Medication Authorization, Psychotropic Medication logs. LPA Rosas conducted interviews with clients, and facility staff that provided information on how clients in placement receive therapy sessions, provide care and supervision and facility services. Report continues on LIC9099-C Page 2 of Based on on site inspections on 05/20/2022, 06/02/022 and video footage dated 05/19/ LPA was able to obtain evidence that C1 did vandalize neighbors and break wooden gate door at time of crisis while staff was at the scene. Facility repaired broken gate door at facility and neighbors, office window and created a taller fence between the facility and neighbors' home. Based on interviews, witness statements, related records reviewed, and video footage dated 05/18/2022, S2 did not follow restraint protocol and conducted inappropriate manual restraint technique C1 which poses an immediate health, safety, and personal rights risks to children in care. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights and Neglect and Lack of Supervision are substantiated. During the inspection investigation the LPA observed deficiencies (see attached 809D), plan of corrections was discussed and appeal rights were provided. LPA Rosas provided a copy of this licensing report to S1. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On December 13, 2022, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas conducted inspection and conducted interviews on May 20, 2022, and June 02, 2022. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated December 13, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegations of staff handling youth inappropriately and youth vandalizing neighbor (s) property the alleged violation occurred; therefore, the findings are substantiated. Report continues LIC-9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 12/13/2022

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

Deficiencies:
87095.65(f): When an inappropriate manual restraint technique is used during an emergency intervention, the licensee must develop a corrective action plan, and as part of the plan...

complaint_status: SUBSTANTIATED

title: Emergency Intervention Staff Training


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
On Wednesday, May 18th, 2022, at 6:30pm Oxnard Police Department arrived and detained minor C1. Oxnard Police Department notified S2, S3 that C1 would be placed on a 72-hr hold at St. John's Regional Medical Center stating that C1 was threatening the staff, clients and destroying property. On May 19, 2022, facility reported to pertinent parties during Child Family Meeting (CFT) about the incident on May 18, 2022, and that they would not be picking up C2 from the hospital. On May 20, 2022, LPA Rosas received a call from S4 stating that they would not picking up C1 from the hospital for the safety of C1, other clients in placement based on the incident that occurred on 5/18/22. On 5/18/22, C1 made verbal threats to neighbor. The facility does not feel safe bringing back C1 to the facility as fear of the verbal threats C1 made to the neighbor. C1 was discharged from St. John's Regional Medical Center on May 20,2022 but stayed in the Emergency Room until arrangements were made for pick up on May 23, 2022. Based on on-site inspections on 06/02/022 and video footage dated 05/19/ LPA was able to obtain evidence that C1 did vandalize neighbors wooden gate door at time of crisis while staff was at the scene. Based on interviews, witness statements, and related records reviewed, the facility did not follow 14-day notice for discharge, the facility did not pick up C2 from the hospital upon discharge, and facility did not follow reporting requirements which poses an immediate health, safety, and personal rights risks to children in care. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights, Reporting Requirements, and Admission Agreement are substantiated. During the inspection investigation the LPA observed deficiencies (see attached 809D), plan of corrections was discussed, and appeal rights were provided. LPA Rosas provided a copy of this licensing report to S1. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On December 13, 2022, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas conducted inspection and conducted interviews on June 02, 2022. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated December 13, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegations of facility did not follow reporting requirements, facility did not follow 14-day notice for minor, and facility refused to pick minor up from hospital. The alleged violations occurred; therefore, the findings are substantiated. Report continues LIC-9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 12/13/2022

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


raw_content:
Narrative:
On 06/18/20232, it was reported that Staff#2 (S2) restricted Child#1 (C1) from going fishing and fishing gear was locked up in the staff office. Interviews revealed that C1 was given the restriction of going finishing during the week and only allowed to go finished during weekends because of poor school grades. The facility limited the fishing outings to help C1 study for finals week and raise their grades. Interviews stated that facility did not threat residents or removed personal items. Facility staff denied the allegation of threatening residents in care as a form punishment. The facility uses the disciplinary style of natural and logical consequences (point system) and utilizes a group-centered treatment program. Facility reported that all discipline as a result from an incident shall be fair, respectful, equal, and consistent. Some of these approved punishments are not receiving full daily points, the temporary removal of earned privileges, restriction, the moving down of a step and in some extreme circumstances the moving down of a level. Interviews noted that some of the resident's property is kept locked in the office closet for safe keeping such as bigger electronics, skateboards, personal snacks, and allowance. The residents school laptops are locked in the office when they were enrolled in virtual learning. Based on all the interviews conducted, it was revealed that the discipline of removing the earn privilege was used as consequence and C1 did not agree with the consequence of limiting daily finish trips. There was not enough evidence and information to corroborate the allegation. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility. Page 2 of 2

Investigation Findings:
13On January 19, 2023, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegations and to deliver the finding. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an inspection and conducted interviews. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 01/19/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegation facility staff threatened a foster child. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 01/19/2023

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


raw_content:
Narrative:
On 09/26/2021, the Department received Special Incident Report (SIR) Client#1 (C1) got into altercation with Client#2 (C2). C2 punched C1 in the left eye. Facility staff immediately separated the two residents. C1 left eyebrow was cut open causing it to bleed. Facility took C1 to St. John's Hospital to get stitches. C1 received five stitches on his left eyebrow. Facility staff to keep increased supervision. LPA Rosas conducted interviews with residents, staff, and pertinent parties regarding to allegations. The staff and clients described the care and supervision of the facility. LPA Rosas ensured to thoroughly review the records of the primary active staff. The facility provided evidence of staff training transcripts stored in RELIAS Training Program digital system with a schedule to complete Hours for new hires and ongoing training for various topics including Trauma Informed, and Pro-Act training. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for clients in placement. There was not enough evidence and information to corroborate the allegations of Neglect and lack of supervision. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The Department has decided that the allegation of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On February 16, 2023, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 02/16/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegation of child sustained unexplained injuries while in care. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 02/16/2023

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


raw_content:
Narrative:
LPA Rosas conducted interviews with residents, staff, and pertinent parties regarding to allegations. The staff and clients described the care and supervision of the facility. LPA Rosas ensured to thoroughly review the records of the primary active staff. The facility provided evidence of staff training transcripts stored in RELIAS Training Program digital system with a schedule to complete Hours for new hires and ongoing training for various topics including Trauma Informed, and Pro-Act training. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for clients in placement. LPA Rosas, review of records for Child#1 (C1) was able to identify that Child#2 (C2) was making treats to C1. From interviews they did not have record of physical altercations from C1 and C2. Facility policy does not allow residents to attack each other verbally or aggressively. Facility reported to always supervise residents and redirect residents in during crisis or altercations with peers. There was not enough evidence and information to corroborate the allegations of Neglect and lack of supervision. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The Department has decided that the allegation of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On February 16, 2023, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 02/16/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegation of staff did not provide a safe environment for minor. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 02/16/2023

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


raw_content:
Narrative:
LPA Rosas conducted interviews with residents, staff, and pertinent parties regarding to allegations. The staff and clients described the care and supervision of the facility. It was reported that Client#2 (C2) had been making verbal threats to residents. C2 would enter Client#1 (C1) and make verbal threats. It was disclosed that staff was present during the incident, but it would happen quickly that de-escalations tactics were unsuccessful and C2 was not receptive. Clients interviewed did not indicate that staff failed to intervene, but residents ignore staff directives. Facility staff did take measures to prevent future incidents by relocating C1 to New Way 1 facility. LPA Rosas ensured to thoroughly review the records of the primary active staff. The facility provided evidence of staff training transcripts stored in RELIAS Training Program digital system with a schedule to complete Hours for new hires and ongoing training for various topics including Trauma Informed, and Pro-Act training. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for clients in placement. There was not enough evidence and information to corroborate the allegations of Neglect and lack of supervision. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The Department has decided that the allegation of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On March 23, 2023, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 03/23/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegation of minor's behavior poses as a risk to other minors while in care is unsubstantiated. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 03/23/2023

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


raw_content:
Narrative:
The Department Centralized Complaint and Information Bureau (CCIB) received a cross reference referral from CPS Hotline report from placement County for Child#1 (C1). Facility reported that C1 had an approved community pass to and is allowed to leave the facility for 30-minute walks unsupervised. On 11/19/2022, C1 returned to the facility with $300 worth of merchandise including a new pair of tennis shoes and a backpack. Facility reported that C1 had the receipts for the items, and it showed that it was paid in cash. On 11/10/2011, C1 outing returned with an iPhone. On 11/21/2022, C1 was questioned about where the iPhone was obtained and reported phone was given by a friend. It was suspected that C1 might be engaging in Commercial Sexual Exploitation of Children (CSEC) activity. C1 did not provide further details. Facility is no longer allowing C1 to have unsupervised 30-minute walks. Facility related the information to the Department and pertinent parties. On 01/05/2023, it was disclosed that C1 met older gentlemen on application and was obtaining gifts. Facility is no longer allowing C1 to have unsupervised 30-minute walks. LPA Rosas provided facility with copy of All County Information Notice NO. I-32- Recommended Practices Regarding Youth Who Have Experienced Commercial Sexual Exploitation and Their Usage of Cell Phones and CSEC Power Point. The facility had Child and Family Team (CFT) meeting to discuss incidents and concerns regarding the suspicious purchases and it was decided that moving C1 to a different location would be beneficial. C1 has been eloping from school and facility. Facility provided additional support for C1 and interventions but C1 was not receptive to them. There was not enough evidence and information to corroborate the allegations of Neglect and lack of supervision. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The Department has decided that the allegation of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On March 23, 2023, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to New Way 2 for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 03/23/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegation of facility staff did not adequately supervise minor while in care is unsubstantiated. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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, FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: VISIT DATE: 03/23/2023

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


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Investigation Findings:
13On 12/20/2023 at 1:51pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above listed facility, for the purpose of concluding the investigation on the above allegation. LPA was met by Facility Manager (FM) who allowed access into the home. The investigation included records review and confidential interviews with, including but not limited to, facility staff members, and clients, as well as residential neighbors to the facility. Based on all interviews conducted, and documents obtained, the Department has found the above allegations to be substantiated, meaning that, the preponderance of the evidence has been met. There was a lack of supervision resulting in loud music being played at 2am and on multiple occasions, causing a disturbance to the community, therefore the finding is substantiated. The facility is issued a citation [See page LIC9099-D for cited deficiencies]. An exit interview was conducted, and appeal rights were discussed. A copy of this report, and appeal rights were provided to the licensee. (Continued on page LIC9099-D) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/28/2023 and conducted by Evaluator Christine Wilson COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:NEW WAY GROUP HOME 2FACILITY NUMBER: ADMINISTRATOR:MENDOZA, ALEXFACILITY TYPE: ADDRESS: RAFT LANETELEPHONE: (805) 201- CITY:OXNARDSTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 12/20/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Facility ManagerTIME COMPLETED:03: PM 9Lack of supervision resulting in damage to neighbor's property Lack of supervision resulting in other issues that affect the safety of the community INVESTIGATION FINDINGS: 13On 12/20/2023 at 1:51pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above listed facility, for the purpose of concluding the investigation on the above allegations.LPA was met by Facility Manager (FM) who allowed access into the home. The investigation included records review and confidential interviews with, including but not limited to, facility staff members, and clients, as well as residential neighbors to the facility. Information obtained did not reveal enough evidence to determine that the allegations, that damage to neighbor's property, and the safety of the community being compromised, as a result of staff not supervising clients. Further, emergency interventions and de-escalation techniques are standard practice. Further, specific dates and times were not provided, and or did not correlate with facility records. Based on all interviews conducted and documents obtained, the above allegations were found to be unsubstantiated, meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. There are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: NEW WAY GROUP HOME 2FACILITY NUMBER: 565801655

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

met_with: Facility Manager


facility_name: OAK GROVE CENTER

raw_content:
Narrative:
Confidential witness statements indicate that facility staff was interfering with R1 telephone calls, and that facility staff did not prevent R1 from going awol. Additional confidential interviews revealed that R1 was not afforded any privacy while in care. CSW stated that R1's phone calls with certain family members were monitored per court order. CSW states that phone calls with certain family members were a trigger for R1 and R1 would engage in self-harm behaviors and suicidal ideation. CSW stated that the facility staff encouraged R1 not to awol. CSW also stated that the facility staff would follow R1 when R1 went AWOL. CSW stated she and Oak Grove treatment team worked together and attempted to meet R1's needs. Based on confidential interviews, the allegation that alleged facility staff was interfering with resident #1 (R1) telephone calls, facility staff did not prevent R1 from awoling and that R1 was not afforded any privacy while in care., may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Tamara Wilson.

Investigation Findings:
13Licensing Program Analyst (LPA) Jose Gonzalez met with Chief Executive Officer (CEO), Tamara Wilson to issue the findings for the above stated allegations. LPA inspected the facility at 11:01am on March 23, 2021, reviewed facility files and one of one residents' file. During the investigation, interviews were conducted with one out of one resident, one out of one facility staff, Program Director (PD), Therapist (TH), Chief Executive Officer (CEO), Clinical Director (CD), and County Social Worker. On March 18, 2021 the department received a complaint that alleged facility staff was interfering with resident #1 (R1) telephone calls, R1 was not afforded any privacy while in care, and that facility staff did not prevent R1 from awoling. Confidential witness statements indicate that staff was not interfering with R1 phone calls and R1 was afforded privacy while in care. Additional confidential interviews revealed that R1's phone call with family member were monitored per R1's county social worker. Confidential witness statements indicate that facility staff encouraged R1 not to awol and would offer R1 other alternatives. Additional confidential interviews revealed that facility staff would follow R1 when R1 went awol. ***CONTINUED on 9099C*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Jose Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 06/22/2021

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


raw_content:
Narrative:
Confidential witness statements indicate R1 does not have a history of inappropriate behaviors nor poor boundaries. Additional confidential interviews revealed that R1 and R2 were placed on boundary protocol and were not allowed to interact. Confidential witness statements indicate that R2 is not assertive and easy influenced by peers. CSW stated that R1 does not have a history of inappropriate behaviors or poor boundaries. CSW also stated R1 has aggressive behaviors. Based on confidential interviews, the allegation that alleged facility staff did not prevent youths from engaging in inappropriate interactions., may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Tamara Wilson.

Investigation Findings:
13On August 26, Licensing Program Analyst (LPA) Jose Gonzalez met with Chief Executive Officer (CEO), Tamara Wilson to issue the findings for the above stated allegations. LPA inspected the facility at 9:22am on May 4, 2021, reviewed facility file and two of two residents' file. During the investigation, interviews were conducted with two out of two residents, two out of two facility staff, Program Director (PD), R Therapist (TH), R Therapist TH2, Chief Executive Officer (CEO), and County Social Worker. On April 27, 2021 the department received a complaint that alleged facility staff did not prevent youths from engaging in inappropriate interactions. Confidential witness statements indicate that staff were supervising the residents. Additional confidential interviews revealed that R1 did not touch R2. Confidential witness statements indicate that facility staff did not observe the alleged incident. Additional confidential interviews revealed that staff had observed R1 went to bed early the night of the alleged incident. Confidential witness statements indicate that facility staff was informed of the incident on the following day. Additional confidential interviews revealed that R1 had touched R2 chest area over R2's clothes. R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 08/26/2021

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


raw_content:
Narrative:
and did not work in the same dorm where C1 resided. Other confidential interviews revealed to be inconsistent but stated that the alleged incident occurred. LPA received inconsistent information and lack of details regarding the allegation. Based on confidential interviews during this investigation, the allegation that staff (S1 & S2) sexually abused client (C1), may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interviewed conducted. A copy of this report and appeal rights were given and explained to Lori Espinoza, Administration Director.

Investigation Findings:
13On September 17, 2021 at 10:15am, Licensing Program Analyst (LPA), Cheraki Davis met with Lori Espinoza, Short Term Residential Therapeutic Program (STRTP) Administration Director to deliver the finding for the above complaint allegation. The investigation was conducted by Special Investigator Lori Wood of the Community Care Licensing (CCL) Investigations Bureau. Investigation included interviews with Riverside County Social Worker, Legal Guardian, Inland Regional Center, Los Angeles Police Department, client (C1), two staff (S1 & S2), Senior Youth Support Worker, Residential Program Director, and Program Assistant Dorm A. Murrieta Police Department and Child Welfare Services/Case Management System Database reports were reviewed. On April 13, 2021, Community Care Licensing received an allegation which stated staff (S1 & S2) sexually abused client (C1). It was reported that staff (S1 & S2) and an unknown staff held C1 down in the bedroom and touched C1 inappropriately in private area. Confidential interviews reported that S1 and S2 denied the allegation. Confidential interviews reported that S2 usually not present at the facility during the day shift UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cheraki Davis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 09/17/2021

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

visit_type: Case Management

met_with: Lori Espinoza, Administration Director


raw_content:
Narrative:
prolonged aggressive and harmful behaviors towards self and others. Confidential information obtained noted that C1 was seen by a nurse and later taken to the hospital and x-rayed after complaining of pain on March 12, 2021, and that no bruising or injuries were observed. According to Confidential information obtained during interviews, C1's pain could have possibly been due to muscle soreness because of C1's combative resistance during restraints. While other confidential information received by Licensing Office stated that the allegations had occurred, and that C1's pain on the left side of their body and the difficulty breathing was due C1 having been inappropriately handled during these restraints. Based on confidential interviews and information obtained, the allegation that Staff inappropriately handled Child #1 (C1) during restraints conducted on March 08, 2021 and March 10, 2021, may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13LPA Mena met with Clinical Director, Billie Gengler to discuss the investigative findings for the above stated allegation. An investigation was conducted by LPAs Jose Gonzalez and Daniel Mena regarding allegations. LPAs Gonzalez and Mena conducted inspections to the Short Term Residential Therapeutic Program (STRTP) on March 25, 2021 at 10:40am and on October 22, 2021 at 1:24pm. No immediate hazards observed. LPAs interviewed six staff (S1, S2, S3, S4 & S5), Lead Nurse, STRTP Clinical Director, STRTP Program Director, STRTP Chief Executive Officer, one of one foster children (C1) involved, as well as reviewed client and facility records. Community Care Licensing received information on March 23, 2021 alleging that Staff inappropriately handled Child #1 (C1) during restraints conducted on March 08, 2021 and March 10, 2021. Information obtained did not corroborate the allegations with a preponderance of evidence. Confidential interviews denied that any staff had ever inappropriately handled C1 during restraints. According to confidential interviews, whenever C1 is restrained, it is always according to protocol and justified, due to C1's UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-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, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 10/27/2021

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

met_with: Billie Gengler


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Based on confidential interviews, there was not sufficient information to determine that staff did not prevent inappropriate sexual behavior of a minor (C1). Although the allegation may have happened or may be valid, there was not a preponderance of evidence to support or deny the allegation. Therefore, the allegation is unsubstantiated at this time. A copy of this report and appeal rights were reviewed and provided to the Facility Representative.

Investigation Findings:
13On October 6, 2022, Licensing Program Analyst (LPA) Val Wilson met with Oak Grove Center Short-Term Residential Treatment Program (STRTP), Chief Executive Officer (CEO), Tammy Wilson, to deliver the findings for the allegation stated above. On October 26, 2021, LPA Wilson conducted an inspection of the STRTP and a review of client records. In addition, the investigation included interviews of the Administrator, Program Director, Clinical Director, Clinical Manager, Therapist, and three clients. See the Confidential Names List, LIC 811, dated October 26, 2021. Additionally, LPA Wilson interviewed the county Social Worker. On October 19, 2021, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent inappropriate sexual behavior of a minor (C1). Corroborating confidential interviews revealed denial of inappropriate sexual behavior amongst C1, C2 and/or C3. Confidential interview with Administrator, Program Director, Clinical Director, Clinical Manager, and County Social Worker indicated it is common for FC1 to make false allegations for attention. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 10/06/2022

met_with: Tammy Wilson


raw_content:
Narrative:
Based on confidential interviews, there was not sufficient information to determine that lack of supervision resulted in a minor (C1) engaging in inappropriate interactions and AWOLing. Although the allegations may have happened or may be valid, there was not a preponderance of evidence to support or deny the allegation. Therefore, the allegations are unsubstantiated at this time. A copy of this report and appeal rights were reviewed and provided to the Facility Representative.

Investigation Findings:
13On October 6, 2022, Licensing Program Analyst (LPA) Val Wilson met with Oak Grove Center Short-Term Residential Treatment Program (STRTP), Chief Executive Officer (CEO), Tammy Wilson, to deliver the findings for the allegations stated above. On November 24, 2021, LPA Wilson conducted an inspection of the STRTP and a review of client records. In addition, the investigation included interviews of the Administrator, Clinical Director, Clinical Supervisor, and three clients. See the Confidential Names List, LIC 811, dated November 24, 2021. On November 17, 2021, Community Care Licensing (CCL) received a complaint alleging that lack of supervision resulted in a minor (C1) engaging in inappropriate interactions and AWOLing. Corroborating confidential interviews revealed minors C1 has AWOL'd with C2 and C3, however, Emergency Intervention Plan (Runaway Plan) was followed. Confidential interview with Administrator, Clinical Director, and Clinical Supervisor indicated C1 has a history of false allegations for attention. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 10/06/2022


raw_content:
Narrative:
During the investigation, confidential interviews stated that there were inconsistences with the information that was being reporting to staff about the incident. Confidential interviews disclosed C1 and C2 shared dorms for one day but upon learning of the incident of an alleged inappropriate behaviors staff removed C2 from C1's dorm. Other confidential interviews stated that following the incident staff set up a boundary plan for both clients that included physical distance and no communication. Another confidential interview stated that C2 had no history of sexual inappropriate behaviors. Confidential interview continued stating that C1 had a history of intrusive behaviors and further added being more acquainted with C2 and in the process of getting to know C1. Another confidential interview stated that a meeting was pending with C1 to further discuss the allegation of the complaint and was unable provide additional information. Another confidential interview stated that C1 was concerned about C2's behaviors due to information obtained from outside sources that alleged that C2 had a history of inappropriate touching. Confidential interview continued stating that there was an incident at the STRTP where C2 brushed up against the front of C1's body. Confidential interview also stated not knowing if C2's behavior toward C1 was an accident or if it was done on purpose. Another confidential interview denied that C2 touched C1 inappropriately. Confidential interview continued stating that C1 was making false allegations against C2 and that C2 was upset and confronted C1 about the allegations. Based on the confidential interviews, the allegation that C2 engaged in inappropriate behavior with C1 in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Oak Grove Center CEO, Tamara Wilson.

Investigation Findings:
13On March 1, 2023, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Oak Grove Center Short Term Residential Therapeutic Program (STRTP) CEO, Tamara Wilson to deliver the investigative finding for the above stated allegation. On January 31, 2022, Community Care Licensing received a complaint alleging that a minor engaged in inappropriate behavior with another minor in care. On February 10, 2022, Licensing Program Analyst (LPA) Valerie Wilson initiated an investigation at the STRTP. LPA Wilson conducted a Health and Safety Inspection, and no immediate deficiencies were observed. LPA Wilson obtained copies of the Short-Term Residential Therapeutic Program staff and client files. Additionally, LPA Wilson conducted three staff interviews (S1, S2, S3) and one client interview (C2). On June 22, 2022, LPA Wilson interviewed Client 1 (C1), a County Social Worker (CSW), and continued an interview with S1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 03/01/2023

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

met_with: CEO, Tamara Wilson


raw_content:
Narrative:
However, the witness was unable to provide the name of the staff member who witnessed the interaction or when the alleged incident occurred. Other confidential interviews did not provide information to support the allegation. Although it was reported that clients (C1, C2, and C3) engaged in inappropriate behaviors during placement, confidential interviews denied observing the alleged misconduct between clients (C1, C2, and C3). Multiple confidential interviews reported that C1 and C3 displayed poor boundaries, and pertinent documentation provided to LPA reported that C1 had various incidents involving exhibitionism. However, confidential interviews, supported by documentation, reported staff was always present to address and redirect C1's behavior. Moreover, confidential interviews reported due to C1's behavior designated staff were assigned to provide increased supervision of C1. Information from confidential interviews also reported that C2 did not interact with C1 or C3. Furthermore, multiple confidential interviews denied a lack of supervision and reported that room visiting is not allowed, and staff conducted frequent room checks while on shift. Based on inconsistent confidential interviews and documentation, the allegation that due to lack of care and supervision, minors (C1, C2, and C3) engaged in inappropriate interactions is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Clinical Director, Billie Glenger.

Investigation Findings:
13On April 29, 2024, at 2: PM, Licensing Program Analyst (LPA) Jessica Peete conducted an unannounced visit to Oak Gove Short-Term Residential Therapeutic Program (STRTP) to deliver the investigative findings for the allegation listed above. LPA Peete obtained documents pertinent to the investigation and interviewed clients (C1 and C3), staff (S1,S2,and S3), and County Social Workers (CSW2 and CSW3). LPA attempted to interview C2 and S4; both did not respond to a request for interviews. On 03/01/2024, Community Care Licensing received an allegation that due to a lack of care and supervision minors (C1,C2,and C3) engaged in inappropriate interactions. A confidential interview reported that clients (C1,C2,and C3) could "sneak away" from staff and engage in the alleged inappropriate behavior due to the lack of supervision. A confidential interview reported that STRTP staff witnessed C1 and C3 inappropriately touching each other. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jessica M Peete LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: OAK GROVE CENTERFACILITY NUMBER: VISIT DATE: 04/29/2024

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

met_with: Billie Glenger, Clinical Director


facility_name: OAKENDELL

raw_content:
Investigation Findings:
13On 11.04. Licensing Program Analyst (LPA) Cecilia Warren met with Paul Mertens, Program Administrator to deliver findings for a complaint with allegations of "Minors engaged in inappropriate sexual behavior while in care" Prior to meeting, LPA reviewed Program Statement, LIC Personnel Report, Child Roster, Staff Schedule, and any Program Fees due for the month of July. LPA reviewed facility complaint history for the past year. During the investigation LPA conducted eleven confidential interviews, a facility inspection and collected Employee Work Schedule, House Rules, Strengths and Needs Plans, Social Worker Case Notes, SIRs, and Emergency Plan. All observations, confidential interviews, documentation, inspections were inconsistent with the reported allegations. The eleven confidential interviews revealed that the youth did engage in inappropriate activities, however there is no evidence to support that it was due to lack of Supervision of staff or their failure to protect the personal rights of the clients in care. The facility monitors the youth regularly and as defined in their work samples and record keeping. The youth have learned the supervision schedule and plan things between those times. The facility is aware of the youth's observations and have increased supervision and rotations of schedules to adapt to the needs of the youth, specifically during timeframes where checking on the youth is required. More staff are participating on check in's and adjusting schedules to ensure youth are healthy and safe. An exit interview was completed with Paul Mertens, Program Administrator, and a copy of this report was emailed to the facility. No Title 22 deficiencies cited. Appeal rights were provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Cecilia Warren LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Paul Mertens, Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Shoua Xiong and Nino Sanders conducted an unannounced Annual/Required Inspection at the facility on 7/15/21 beginning at 11:30AM. LPAs met with Paul Mertens, Executive Director/Administrator, and explained the purpose of the inspection. This facility is licensed for 18 clients and currently serves 6 clients. On today's date, a Health and Safety Inspection was conducted of the facility. This facility has two main houses that residents are able to stay in. Currently, only the "Main House" is utilized while the "Tea House" is unoccupied. On grounds is what is referred to as the "Staff Corridor" building which consists of an Administration Office, Classroom, and Pantry. This facility also contains a basketball/tennis court area along with a garden and chicken coop area. During the inspection of the Main House where clients stay and sleep in, LPAs observed that no more that two clients in care shared a bedroom. All clients were provided with their own beds with beddings, dressers, and closet space for personal storage. Each client also had their own individual basket of hygiene products. Each bedroom was observed with an operational smoke detector. Personal Rights poster was posted in a public area. In the kitchen area, menus were displayed on the refrigerator. The refrigerator and pantry was stocked with the required amount of both perishable and non-perishable food items. Smoke Detectors and Carbon Monoxide detectors were present in each building. Client files were observed to be locked in an office. This office also contained client medications which were locked in a glass cabinet and the Medication Administration Record binder. Throughout the facility grounds, there are areas where clients are able to participate in recreational activities, which also includes Archery. There are four storage sheds and one workshop barn on the property and they were all observed to be locked. LPAs also reviewed six client files. All required documents were present. No deficiencies were noted in client files. LPAs also interviewed three clients in care. LPAs were unable to finish the Annual Inspection and will return on another date and time. No citations were issued on today's date. Exit interview conducted and a copy of this report was left at the facility with Paul Mertens, Executive Director/Administrator.

report_type: Facility Evaluation

visit_type: Annual

met_with: Paul Mertens, Executive Director/ Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong and LPA Nino Sanders had conducted an unannounced inspection visit to the facility on 7/15/2021 beginning at 11: AM. LPAs met with Paul Mertens, Executive Director/Administrator and explained the purpose of the visit was to conduct an inspection of the facility for the purpose of completing their Annual/Required inspection and for the permanent Licensure of the facility. This facility is currently provisionally licensed to serve 18 clients. There were six clients placed in care at the time of the inspection. On today's date, LPAs conducted a tour of the facility, reviewed six client files, and interviewed two clients. There were no observable safety concerns or safety hazards during today's inspection. No deficiencies were cited. LPAs are recommending Permanent Licensure of this facility, pending on Management review. Exit interview conducted and a copy of this report was left with Paul Mertens, Executive Director/Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong and LPA Robert Sandles conducted an unannounced inspection visit to the facility on 7/29/21 beginning at 10: AM. LPAs met with Paul Mertens, Executive Director/Administrator and explained the purpose of the visit was continue the Annual/Required inspection and complete the review of Staff Records. On today's date, LPAs reviewed ten staff records (S1-S10). LPAs observed that Staff S2 did not have a current CPR/First Aid certificate. However, the facility stated that this staff had suffered a medical condition which caused them to miss the last scheduled training for CPR and First Aid. Facility stated the staff is signed up and will complete training. Proof of training will be emailed to LPA. LPAs also observed that Staff S2, S3, and S4 did not have current performance evaluations. Staff S2 has not had an evaluation since 5/9/2018. Staff S3 and S4 has not had any evaluations since their hiring dates in 2017. The facility is being cited for violations of Interim Licensing Standards (ILS) sections 87066(b)(6) Staffing Records: The licensee shall maintain the following personnel records: A record of each performance evaluation and any correspondence with the employee. Exit interview conducted and a copy of this report was given to the Paul Mertens, Administrator/Executive Director.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/18/ Licensing Program Analyst (LPA) Jean Stidman met with Paul Mertens, Executive Director for the purpose of conducting a case management inspection regarding an incident that occurred on 12/25/22. LPA reviewed medication logs for 10 clients and observed six clients Medication Administration Record (MAR) for January 2023 are missing a specific time to administer medication in the evening/bedtime. Facility will add a specific time to administer medication in the evening/bedtime on all MAR for January 2023 by the close of business on 1/19/23. LPA reviewed the facility medication administration procedures and medication incident reports for 2022 with Paul Mertens.

met_with: Paul Mertens, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 10/6/23 at 10:30am. During the inspection LPA met with Mary Baron, Clerical who assisted with the inspection. LPA Stidman conducted a walk-through of the facility inside the main house. LPA observed the facility staff-client ratio at time of inspection was four staff to ten clients. Number of staff interviewed one. Number of clients interviewed five LPA observed # six bedrooms, # three_bathrooms. LPA Stidman inspected and/or reviewed the following: Posting of license_yes Personal Rights yes _ Disinfectants/Cleaning solutions inaccessible_yes Refrigerator Temperature at or below 45 degrees F _33 degrees Freezer Temperature at or below 0 degrees__-6 degrees_ Nonperishable Foods one week and fresh perishable foods two days minimum_yes _ Menu present and posted__yes_ Working telephone _yes Carbon monoxide detectors yes Smoke Detector _yes Common Room available_yes Dining area (enough seating, furniture good condition, not broke or damaged) _yes Medication centrally stored, locked/inaccessible _yes Office (locked and privacy) __yes _ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F 122 degrees Facility has warnings signs posted, Fire Extinguisher (note inspection date) serviced August 2023_Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _yes _ Soap and Paper towels _yes Laundry Facilities(available) _yes Bedrooms-required linen and furnishings __yes Facility free of vermin _yes Bedroom (required bedding/furniture, furniture in good repair) _yes The following items were reviewed for compliance in the regional office prior to the facility inspection: Annual fees, Accreditation Name and Expiration Date: _5/31/24, Mental Health Program Certificate Expires: 7/9/24, No Waivers or Exceptions. An exit interview was conducted and a copy of this report was left with Mary Baron, Clerical.

met_with: Mary Baron, Clerical


summary: Facility Evaluation - 4 deficiencies

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 10/9/23 at 10:00am. During the inspection LPA met with Lisa O'Donnell COO/Assistant Executive Director who assisted with the inspection. LPA conducted a walk-through of the facility's sheds, TEA House inside and out. Facility staff-client ratio at time of inspection were 11 staff and 10 kids present. Number of staff interviewed two_ LPA observed TEA House has # _five_bedrooms, # _four_bathrooms a living room, kitchen, gym, rec room, music room and laundry room. LPA Stidman inspected and/or reviewed the following: II. Operations Complaint Procedures For Youth Reviewed yes__ Board Minutes Reviewed_yes CQI Report Reviewed yes III. Disaster Preparedness Disaster and mass casualty plan updated and available_yes_ Quarterly Drills conducted and documented__No_ Disaster preparedness supplies verified yes_ The facility failed to conducted fire drills quarterly from September 2022-September 2023. IV. Emergency Intervention Staff training yes V. Staffing/Volunteers Number of Staff files reviewed five_Criminal record clearances verified yes First Aid Certificate yes Certified Administrators certificate valid and current yes Staff training verified yes Job title/qualification verified yes_ VI. Client Records Number of Clients files reviewed five_Needs and Services Plan _Not developed or updated within 30 days for four out of five files reviewed__ Centrally Stored Medication and log reviewed yes JV Reviewed yes Psychotropic Medication and log reviewed yes Cash Resources_yes_ Compatible Assessment yes. The facility cited violation of Title 22 regulation 80026(h) Safeguards for Cash Resources and Personal Property, and Valuables for one out of five client's balance sheet total was inaccurate. The facility cited violation of Interim Licensing Standard (ILS) Regulation 87068.2(a) Needs and Services Plan and ILS Regulation 87068.22(b) Needs and Services Plan for Non-Minor Dependents for the initial Needs and Services Plan (NSP) was not completed or updated at least every 30 days for four out of five client files reviewed. VII. Core/Therapeutic Services Trauma Informed Practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) yes_ An exit interview was conducted and a copy of this report was left with Lisa O'Donnell COO/Assistant Executive Director

Deficiencies:
87065(d): Deficient Practice Statement
1
2
3
4Based on record review, the licensee did not comply with the section cited above in five out of five staff files reviewed and discussion with adminstrator's designee the facility does not have any staff trained  to apply the reasonable and prudent parent standard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
1
2
3
4
87068.2(a): Deficient Practice Statement
1
2
3
4Based on record review, the licensee did not comply with the section cited above in
87068.3(a): Deficient Practice Statement
1
2
3
4Based on record review,  the licensee did not comply with the section cited above in
80026(h): 80026(h) Safeguards for Cash Resources and Personal Property, and Valuables. Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following

title:
Personnel Requirements

(d) The licensee shall designate at least one staff member to be onsite at all times to apply the reasonable and prudent parent standard to decisions involving the participation of a child in age or developmentally appropriate activities in accordance with Health and Safety Code section 1522.44(b) and Section 87067.

This requirement is not met as evidenced by

title:
Social work staff shall obtain the information specified in Section 87070, and shall develop an individual needs and services plan, within 30 days of placement....

This requirement is not met as evidenced by

title:
Modification to the Needs and Services Plan. The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days....

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On 4/23/24 at 10: AM Licensing Program Analysts (LPA) Kayla Green met with Theresa John assistant to the directors for the purpose of a case management for an incident that occurred on March 16, 2024. It was reported that a client had missed medication due to client leaving early in morning to go visit his parent and the staff forgot to give to it to him. When medications were distributed at 8:30AM, the medications was notice and the client was contacted. The client stated he felt fine and the doctor and on site supervisor was notified. The staff was given additional training and the error was logged. LPA reviewed medication logs for 11 clients and observed six clients Medication Administration Record (MAR) for March and April 2024. LPA didn't see any errors when it came to logging the medication information. LPA also spoke with Paul Mertens about their procedures for training when it comes to medications and logging it. He stated " Licensed psyc tech gives the staff training on logging the medication, any missed errors that happen by staff she retrains that staff member on the procedures. As well, we have staff meetings where we go over the procedures of logging the medications in the binders and any changes when it comes to logging the medications." Exit interview conducted and a copy of this report and appeal rights is left with Theresa John.

met_with: Theresa John


raw_content:
Narrative:
Interviews conducted with County Social Worker, Probation Officer, four staff and two clients established that there was not any intent to harm youth if contact was made by the staff and the minor. All interviews except one state that the minor charged at the staff during an escalation. The photo that was sent to LPA does show a dark brownish/greyish color mark above the belly button on the stomach of a male, but there is not a face on the picture to identify who the person in the picture is nor is there a time or date stamp on the picture to show when it was taken. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation of staff caused injuries to a minor while in care is unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Michael Gilbert, Administrator whose signature on this form confirm receipt of these document.

Investigation Findings:
13Licensing Program Analyst (LPA) Carolyn Flynn made an unannounced visit to the above listed facility to inform them of the findings for the above listed complaint. LPA met with Michael Gilbert, Administrator (Adm) at 9: AM on 08/25/2021. During the investigation, LPA Flynn conducted confidential interviews with two clients, Bio-Mother (BM), County Social Worker, Probation Officer and four staff members. LPA attempted to call and email the Reporting Party (RP) on 07/13/2021 and left message requesting a call back but did not hear back from RP so LPA called again on 08/10/2021 and was told RP was no longer with the department and referred to new social worker. LPA Flynn conducted interviews between July and August 2021. LPA Flynn reviewed and obtained copies of needs and service plans, incident reports from 05/24, 05/25, 06/04, and 07/08/2021, staff schedules and current staff phone list from Adm on 07/14/2021. LPA obtained and reviewed a copy of the Gilroy Police Report filed on 05/24/2021 and a photo that was sent to LPA Flynn on 08/11/2021 by BM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Carolyn Flynn 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 26-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. First Street, Ste. FACILITY NAME: ODD-FELLOW REBEKAH CHILDREN'S HOME OF CALIFORNIAFACILITY NUMBER: VISIT DATE: 08/25/2021

met_with: Michael Gilbert


facility_name: ODD-FELLOW REBEKAH CHILDREN'S HOME OF CALIFORNIA

summary: Facility Evaluation

raw_content:
Narrative:
Closure Meeting: Odd-Fellow Rebekah Children's Home of California - Location: Virtual meeting via Microsoft Teams Attendees: Rebekah: Michael Gilbert - STRTP Program Administrator/Campus Services Program Manager (Adm), and Julio Villarreal, LCSW - Chief Clinical Officer (CCO) Department Family Children Services: Cynthia Elkins - Placement Supervisor for Santa Clara County Department of Health Care Services: Gabriel Pacheco - AGPA | Children's Therapeutic Care Unit CCL: Nelson Martinez - Regional Manager (RM), Helga Wong - Licensing Program Manager (LPM), and Carolyn Flynn - Licensing Program Analyst (LPA) The purpose of this meeting is to review over the closure plan set for August 25, 2021. During the meeting we discussed the obstacles and challenges that lead to the closure, the plan for the last client in care, and plan for the future of the program. As a result of this meeting, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Michael Gilbert, Administrator with a request to sign and send back a signed copy for the files.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Carolyn Flynn made an unannounced visit to the above listed facility at 9: AM on 08/25/2021. LPA met with Michael Gilbert, Administrator (Adm) to tour the facility and confirm the last client has been removed from campus. At 9: AM, Adm escorted LPA through the facility. LPA observed the six open bedrooms were empty and no clients are residing in the facility. LPA confirmed that the last client discharged on 08/24/2021. The facility is no longer operational and Adm returned the STRTP License to LPA Flynn. As a result of this visit, there were no California Code of Regulations, Title 22, Division Chapter 5 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Michael Gilbert, Administrator whose signature on this form confirm receipt of these documents


facility_name: OLIVE CREST-HOPE REFUGE

raw_content:
Investigation Findings:
13On 4/13/23 at 10:45:am Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of initiating an investion related to above allegation. LPA spoke with the Residential Program Director and together, discussed the investigative finding. During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegations. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that S1 failed to conduct job duty as specified, in a way that would ensure the safety and supervision of children in care. Further confidential interviews revealed that facility van keys are not secured in a manner that would prevent children in care from gaining access to them Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED and a deficiency is being cited today. See attached LIC 9099D. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: OLIVE CREST-HOPE REFUGEFACILITY NUMBER: 425802141

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

met_with: David Harper, Program administrator (RPD)