state: CA

facility_name: MANUCH, INC.

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Lourey Bartolome contacted Manuch Inc. and met with Administrator Garnett Fountain to discuss the findings on this investigation. Licensing Program Analyst conducted the investigation that included review of documentation and interviews. Based on the information obtained, the above mentioned allegations could not be proven with a preponderance of the evidence. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Melanie Krage LICENSING EVALUATOR NAME: Lourey Bartolome LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

report_type: Complaint Investigation

met_with: Garnett Fountain

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Priscilla Zamudio conducted a complaint inspection to the STRTP and met with Jhustin Granados, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. LPA observed the television in the client's bedroom unsecured and unstable on top of a small cardboard box, placed on the chest of drawers. It was immediately removed by staff. Based on observation and interviews, there is a preponderance of the evidence to prove the above allegation is substantiated. The agency is being cited for a violation of the California Code of Regulations, Title 22, Division 6, Section 80087(a), Buildings and Grounds. An exit interview was conducted with Jhustin Granados, Facility Manager and a copy of this report, and appeal rights were provided. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Priscilla Zamudio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: MANUCH, INC.FACILITY NUMBER: 107202620

met_with: Jhustin Granados


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Jhustin Granados. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Boyd conducted interviews with clients, stafff and complainant. The interviews revealed that there is no consistent consensus as to whether the allegations listed above happened or didn't happen. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On July 28, Licensing Program Analyst (LPA) Wayne Aoki conducted a follow-up complaint inspection at the facility. LPA was met by Assistant Manager, Rochelle Lupio. The purpose of the inspection is to deliver the findings for the above complaint allegation. Based on confidential interviews and information obtained during the investigation, there is a preponderance of the evidence to prove the above allegation is substantiated. The facility is being cited for a violation of the California Code of Regulations, Title 22, Division 6, Section 80078(a), Responsibility for Providing Care and Supervision. An exit interview was conducted with Rochelle Lupio, Assistant Manager and a copy of this report, and appeal rights were provided. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: MANUCH, INC.FACILITY NUMBER: 107202620

met_with: Rochelle Lupio

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Manuch Inc, Aspen House and met with Facility Manager Elena Yrigollen to deliver findings of investigation. CS and Investigator Lomeli conducted investigation that included review of documentation and confidential interviews. Based on inconsistencies in the information obtained a preponderance of the evidence could not be found that the allegations occurred as reported. 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. Copy of this report and Appeal Rights left at the facility at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney 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: Elena Yrigollen


raw_content:
Investigation Findings:
13On April 25, 2023, Licensing Program Analyst traveled to Manuch Inc. - Aspen House to conclude the investigation with regards to above allegation. LPA was met by facility representative .Elena Yrigollen During the course of the investigation, LPA conducted confidential interviews with staff and minors in care. Based on these interviews, the allegation may have happened or is valid, there is not a preponderance of the evidence, therefore, the above allegation is unsubstantiated. Based on the above, the complaint is Unsubstantiated. There were no deficiencies cited during this inspection. A copy of this report and appeals rights were left with Ms. Yrigollen UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On June 6, 2023, Licensing Program Analyst (LPA) Wayne Aoki traveled to Manuch Inc. - Aspen House to conclude the investigation with regards to above allegation. LPA was met by facility representative Larry Thao During the course of the investigation, LPA conducted confidential interviews with staff and minors and obtained other documents. Based on these interviews and documents. Although the allegation may have happened or is valid, there is not a preponderance of the evidence. Therefore, based on the above, the complaint is Unsubstantiated. There were no deficiencies cited during this inspection. A copy of this report and appeals rights were left with Mr. Thao UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Larry Thao


raw_content:
Investigation Findings:
13On December 20, 2023, Licensing Program Analyst (LPA) Briana Placencia conducted a complaint inspection at Manuch Aspen House and met with Irving Hermosillo. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Briana Placencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Irving Hermosillo


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Reyna Martinez and Melissa Renovato on May 20, 2026 at 12:35pm. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Sabrina Sanchez, Direct Care Staff. The purpose of the inspection was to conduct client interviews as clients were not available for interview during the initial inspection on May 7, 2026. The clients declined to be interviewed during this inspection. LPAs provided a copy of the licensing report to Direct Care Staff, Sabrina Sanchez. No deficiencies are being cited at this time. LPAs conducted exit interview with Sabrina Sanchez, Direct Care Staff.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Sabrina Sanchez


facility_name: MANUCH INC- INSPIRATION PEAK

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On November 20, 2023, Licensing Program Analyst (LPA) Briana Placencia conducted a complaint inspection at Manuch-Inspiration Peak and met with Jessica Villalba. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA conducted confidential interviews which revealed that staff did not provide adequate supervision to the minors in care, in that a youth absconded attempting to obtain the Wi-Fi password from neighbors. Staff on shift could not leave due to begin only staff at the time. Confidential interviews, documentation and video footage reveal that staff did not prevent minors from causing harm to minor in care. Based on the information obtained, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Briana Placencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MANUCH INC- INSPIRATION PEAKFACILITY NUMBER: 107207213

met_with: Jessica Villalba


raw_content:
Investigation Findings:
13On May 9, Licensing Program Analyst (LPAs) Miriam Flores and Reyna Martinez conducted a complaint inspection at Manuch-Inspiration Peak and met with Jessica Villalba. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPAs conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Miriam Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


investigation_findings: 13On May 9, Licensing Program Analyst (LPAs) Miriam Flores and Reyna Martinez conducted a complaint inspection at Manuch-Inspiration Peak and met with Jessica Villalba. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPAs conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Miriam Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


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


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


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

met_with: Adrian Pena


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Reyna Martinez conducted a complaint inspection and met with Adrian Pena, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging staff did not ensure faciltiy was free from mold; Staff did not ensure there was the required amount of food for minors in care. LPA conducted interviews and obtained documentation.There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On November 7, Licensing Program Analyst (LPA) Miriam Flores conducted a complaint inspection and met with Facility Manager, Adrian Pena. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging staff hit a minor in care, staff engaged in a verbal alteraction with minors, staff did not store an adequate amount of food for minors in care. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Miriam Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


facility_name: MANUCH INC-RIVERPINE

raw_content:
Investigation Findings:
13On January 8, 2024, Licensing Program Analyst (LPA) Briana Placencia conducted a complaint inspection at and Manuch Riverpine met with Ana Soito. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Briana Placencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Ana Soito


summary: Facility Evaluation

raw_content:
Narrative:
On 7/1/22, Licensing Program Analyst (LPAs) Lisa Slusher, Reyna Martinez, Briana Placencia travelled to the facility listed above to conduct a prelicensing inspection. Facility Inspection conducted. Met at the facility by Licensee Mike Manucharyan, Clinician Elena Manucharyan, Administrator Levon Manucharyan. 1. Facility Grounds contain unlocked chemicals and other items (charcoal grill, lighter fluid, pool chemicals). There is a pool on the property that is currently unfenced and also is green and in need of appropriate cleaning and chemical balance if it is to be used. 2. Outdoor space observed. There are items to be removed, and licensee is to provide outdoor activities. . 3. Chemicals were in unlocked areas upon inspection. . 4. Locked and centrally stored medications were discussed. There is not currently a locked space for medications... 5. First aid kit complete with appropriate manual was not present upon inspection. 6. Adequate storage space observed. 7. Individual beds in good repair observed in the garage, but were not yet set up in the house.. 8. The house has 3 bedrooms, double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. Only one bedroom will be in use and is furnished at this time. 9. Adequate food storage space observed. Perishable and non perishable foods were not observed at this time. 10. Weekly menu not observed. 11. Dining room observed. Table and chairs for the STRTP were not observed during inspection. 12.Facility has two full restrooms, one for client use, one for staff use, both are operable. Facility is to ensure water temperature is maintained between 105 and 120 degrees 13. Licensee has a vehicle for use at the facility. When LPA returns, the vehicle including insurance and registration will be available for inspection. 14. Licensee provided transfer requests for board member, administrator, and therapist . Licensee will submit a transfer request for a corporate board member. Fire clearance request has been provided to the city of Fresno Fire Department. The facility requires fire clearance prior to licensure. The facility physical plant requires a deep cleaning. The previous tentant is still in the process of removing their belongings, so that the licensee can move in furniture. The physical plant also smells of cigarette smoke. The licensee provided verification from the City of Fresno Planning department of overconcentration clearance on this date. LPA will conduct a follow-up inspection to verify all the requirements on these two pages are met. LPA will also provide a pre-licensing certification to be submitted back to LPA prior to repeat inspection tentatively scheduled for 7/8/22.

visit_type: Prelicensing

met_with: Mike Manucharyan, Levon Manucharyan, Elena Manucharyan, Garnett Fountain


summary: Facility Evaluation

raw_content:
Narrative:
On 7/1, Licensing Program Analyst (LPA) Lisa Slusher travelled to the facility listed above to conduct a follow up case management to the initial prelicensing inspection. Facility Inspection conducted. Met at the facility by Board Designee Mike Manucharyan and Administrator Levon Manucharyan. 1. Facility Grounds inspected and observed to be free from hazard with appropriate activity space observed. . 2. Facility pool was adequately fenced upon inspection. A lock was to be added by the licensee. outdoor activity space observed. 3. Chemicals stored in a locked cabinet 4. Observed locked cabinet inside locked closet for central storage of medications. Observed first aid kit and manual. 5. Individual bed in good repair observed, along with an appropriate amount of storage space. 6. The house has 3 bedrooms, sufficient for double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. Only one bedroom will be in use and is furnished at this time. 7. Adequate food storage space observed. Perishable and non perishable foods were not observed at this time. 8. Dining room observed with appropriate table and chairs. 12.Facility has two full restrooms, one for client use, one for staff use, both are operable. Facility is to ensure water temperature is maintained between 105 and 120 degrees 9. Licensee has a vehicle for use at the facility with appropriate insurance and registration. 10. Licensee provided transfer requests for board member, administrator, and therapist and all have been completed. 11. Fire Clearance received for the facility Facility has met requirements for initial licensure. STRTP will be licensed for 1 ambulatory client.

met_with: Levon Manucharyan, Mike Manucharyan


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA Lisa Slusher conducted a scheduled case management for the purpose of evaluating a facility for a increase in capacity. The facility was licensed as an STRTP for 1 on 7/20/22. The facility is increasing the capacity of the facility to 3. The facility will remain a specialized rate facility for higher level youth. The facility will not expand their census unless youth are found to be compatible with the current resident or the current resident is discharged. 1. Facility Grounds inspected and observed to be free from hazard with appropriate activity space observed. . 2. Facility has had a fire inspection for increased capacity and has verbally been told that a clearance is forthcoming- fire clearance has not yet been received by CCLD, 3. Chemicals stored in a locked cabinet 4. Observed locked cabinet inside locked closet for central storage of medications. Observed first aid kit and manual. 5. Individual bed in good repair observed, along with an appropriate amount of storage space. 6. The house has 3 bedrooms, sufficient for double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. Only one bedroom will be in use and is furnished at this time. 7. Adequate food storage space observed. Perishable and non perishable foods were not observed at this time. 8. Dining room observed with appropriate table and chairs. Facility has 2 full restrooms, one for staff use and one for client use. Facility is to ensure water temperature is maintained between 105 and 120 degrees. 9. Licensee has a vehicle for use at the facility with appropriate insurance and registration. Facility has met requirements for capacity increase, pending the receipt of the fire clearance. Facility is to follow up with LIC 500 and 9020, LIC 308 309.

met_with: Mike Manucharyan, Elena Manucharyan, Levon Manucharyan


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Candice Fulmer, Direct Care Staff and inspected the facility, inside and out. Facility Grounds are clean and free of debris or observable hazards. Adequate indoor and outdoor activity space and materials observed. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced July 2023. The facility is working on their accreditation with CARF and will keep CCL updated on this matter. MHPA was given an extended six months provisional to January 2, 2024 by CCL. The facility will keep CCL updated on final status. The house has 2 client bedrooms, one single occupancy and one double occupancy. Individual beds were observed with appropriate clean linens. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 75 degrees. Hot water temperature measures 110 degrees. Facility has no cameras in the facility. No firearms or weapons are allowed in the facility. Facility has a pool that is fenced with a self latching device and compliant with regulations. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 administrator, 1 facility manager, and 10 direct care staff. -Continued on LIC809-C. Personnel Files are maintained at the main office. 5 staff files were reviewed. 1 staff was available to be interviewed. 3 records of clients were reviewed and 1 client was available to be interviewed. 1 client is on a 52/50 status and 1 client refused to speak with LPA. A review of Licensing Information System on July 18, 2023, indicates that all facility staff associated to the STRTP have DOJ, FBI, and child abuse index clearances. No deficiencies are being issued today. A copy of this report and appeal rights were discussed and left with the STRTP.

visit_type: Annual

met_with: Candice Fulmer


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPAs) Miriam Flores and Briana Placencia conducted a case management visit at the STRTP and met with Administrator, Levon Manucharyan. Incidents reports submitted to the Department on 5/24/24 were discussed and reviewed during this inspection. Technical Advisory was issued and discussed. An exit interview was conducted and a copy of this report was provided to Administrator, Levon Manucharyan.

met_with: Levon Manucharyan


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs), Miriam Flores and Briana Placencia at Manuch Inc-Riverpine STRTP in Fresno, CA. LPAs met with Administrator, Levon Manucharyan. A physical plant inspection was conducted and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. 2 clients require medications currently, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Facility is CARF accredited until August 31,2025 and approved through the Department of Behavioral Health through January 16, 2025. Two technical advisors were discussed during this inspection. Facility was cited on ILS regulation 87087(d) and CCR 80088(b). Exit interview was conducted. A copy of this report was provided to the Administrator and Appeal of Rights


summary: Facility Evaluation

raw_content:
Narrative:
On September 5, 2024, Licensing Program Analyst (LPA) Miriam Flores conducted a case management visit at the STRTP and met with Facility Manager, Ana Soito. LPA reviewed and discussed the incident report dated 08/02/24. Facility Manager explained their daily procedure for room search and supervision. No deficiencies observed or cited during today's inspection. An exit interview was conducted and a copy of this report was provided via email to Facility Manager, Ana Soito due to technical issues.


summary: Facility Evaluation

raw_content:
Narrative:
On April 27, 2026, Licensing Program Analyst (LPA) Miriam Flores conducted an unannounced case management inspection at the STRTP and met with Direct Care Staff, Fran Reyes. Administrators, Levon Manucharyan and Garnett E.D. Fountain participated via phone. During the investigation of a complaint it was discovered that the facility has ongoing issues with scheduling appointment with their psychiatrist. This concern will be addressed by the facility, they have agreed to reassess the services their psychiatrist is able to provide to meet the needs of their youth in placement. No citation were issues. Exit interview was conducted and a copy of this report was left at the facility. .

met_with: Fran Reyes


raw_content:
Investigation Findings:
13On April 27, Licensing Program Analyst (LPA), Miriam Flores conducted a complaint visit to Manuch Riverpine to deliver the findings on the listed allegations. LPA met with Direct Care Staff, Fran Reyes and Administrator, Levon Manucharyan participated via phone. The Department has investigated the complaint alleging that staff did not ensure that the minor was seen by a doctor and staff did not prevent minor in care from bringing drug paraphernalia into the facility. There were inconsistencies in the documentation collected. Although the allegation may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Miriam Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Facility Evaluation

raw_content:
Narrative:
On May 20, 2026, Licensing Program Analyst (LPA) Miriam Flores conducted a case management inspection at Manuch Riverpine, STRTP and met with Facility Manager, Isabel Lopez. The purpose of this inspection is to follow up on an incident report that was sent to the Licensing Department. Incident report submitted to the Department is dated 4/17/2026. The incident report reviewed was regarding youth in placement's behaviors that escalated and led to an AWOL incident report. Staff provided alternatives to de-escalate behaviors and youth declined. There were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided to the Facility Manager.

met_with: Isabel Lopez


facility_name: MARY'S SHELTER - HOUSE 1

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
the allegation that C1 was assaulted by another minor while in care due to lack of supervision. Therefore, the allegation is unsubstantiated. An exit interview was conducted and appeal rights were discussed with Clete Menke, Operations Director. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On January 23, 2023, at 12:25 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Clete Menke, Operations Director, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 11/01/2022 at 10:15 am and no deficiencies were observed. LPA Linley interviewed two clients (C1, C2), two clients declined to be interviewed (C3, C4), and six staff (S1-5, S7), one staff was unable to be interviewed (S6), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: child history report, client roster, October 2022 staff schedule, special incident report, and shift notes. On 10/27/2022, Community Care Licensing received an allegation that C1 was assaulted by another minor while in care due to lack of supervision. Based on record reviews and confidential interviews, C3 pulled C1's hair. The details gathered for the incident did not provide a preponderance of evidence to prove or disprove UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-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, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 01/23/2023

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

met_with: Clete Menke, Operations Director


raw_content:
Narrative:
Confidential interviews revealed facility staff verbally advised C1 of a 14-day notice during a Child and Family Team meeting held on January 05, 2022, however, facility failed to operate in accordance with their plan of operation and submit notification to authorized representative within seven days. On January 20, 2022, CCL received an allegation staff did not provide minor with clothing allowance. Specifically, it was reported that C1 was not provided C1's clothing allowance for the month of January 2022. Confidential interviews revealed in January 2022, facility had high cases of COVID and staff asked C1 to wait a couple weeks until the COVID cases had dropped prior to going shopping with monthly allowance. Confidential record review revealed C1 would go shopping in the beginning of the month and at the time of discharge C1 still had not gone shopping and was not given monthly allowance of $75.00 at time of discharge. Based on confidential interviews and record review, the allegations unlawful eviction of C1 and staff did not provide C1 with clothing allowance are substantiated and the facility is being cited for violation of Short Term Residential Therapeutic Interim Licensing Standards Version 4. Plan of Operation 87022(f). An exit interview was conducted, and a copy of this report and appeal rights were provided to facility representative. Confidential interviews revealed client was unable to take all personal belongings at the time of discharge as the car was full. Confidential interviews shared minor was given all confidential and personal documents at the time of discharge in a binder. Confidential interviews also revealed facility staff followed-up with C1 after discharge and provided C1 with all remaining belongings and any mail that was received after discharge. Another confidential interview stated that C1 was not provided C1's birth certificate. Based on confidential interviews and record review, the allegation that staff did not provide C1 with personal belongings may have occurred, however, it is not supported or proven by evidence. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided to facility representative.

Investigation Findings:
13On June 15, 2022 at 03: PM, Licensing Program Analyst (LPA), Lisi Leon, met with Mary's Shelter's, Quality Assurance Specialist, Iman Farooqui, to deliver the finding for the above stated allegation regarding the Short Term Residential Therapeutic Program (STRTP). LPA spoke with Facility Administrator by telephone who authorized Iman Farooqui to sign and receive report. On January 27, 2022, LPA Leon completed a safety and health inspection and no immediate health & safety concerns were observed. LPA Leon conducted interviews with Facility Administrator (FA), one Staff Manager (SM), one County Social Worker (CSW), one Agency Social Worker (ASW), three staff Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3), one After-Care Director (AD), and two residential clients Client #1 (C1) and Client #2 (C2). LPA Leon obtained copies of the facility and client roster including schedules and reviewed client records. On January 20, 2022, Community Care Licensing (CCL) received an allegation that staff did not provide minor with personal belongings. Specifically, it was reported that C1 was not provided C1's birth certificate. ****This is an amended report of the report issued on 06/15/2022**** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Lisi Leon 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 CCLD Regional Office, THE CITY DR., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/20/2022 and conducted by Evaluator Lisi Leon PUBLICCOMPLAINT CONTROL NUMBER: 22-CR- FACILITY NAME:MARY'S SHELTER - HOUSE 1FACILITY NUMBER: ADMINISTRATOR:ELLEN ROYFACILITY TYPE: ADDRESS: E. 17TH STREETTELEPHONE: (714) 730- CITY:SANTA ANASTATE: CAZIP CODE: CAPACITY:17CENSUS: 13DATE: 06/15/ UNANNOUNCEDTIME BEGAN: 03: PM MET WITH:Quality Assurance Specialist, Iman FarooquiTIME COMPLETED:05: PM Staff did not provide minor with clothing allowance INVESTIGATION FINDINGS: 13On June 15, 2022 at 03: PM, Licensing Program Analyst (LPA), Lisi Leon, met with Mary's Shelter, Quality Assurance Specialist, Iman Farooqui to deliver the finding for the above stated allegations regarding the Short Term Residential Therapeutic Program (STRTP). LPA spoke with Facility Administrator by telephone who authorized Iman Farooqui to sign and receive report. On January 27, 2022, LPA Leon conducted a safety and health inspection was completed on January 27, 2022 and no immediate health & safety concerns were observed. LPA Leon conducted interviews with Facility Administrator (FA), one Staff Manager (SM), one County Social Worker (CSW), one Agency Social Worker (ASW), three staff, Staff #1 (S1), Staff #2 (S2) Staff #3 (S3), one After-Care Director (AD), and two residential clients, Client #1 (C1) and Client #2 (C2). LPA Leon obtained copies of the facility and client roster including schedule and reviewed client records. On January 20, 2022, Community Care Licensing (CCL) received an allegation the facility conducted an unlawful eviction. Specifically, it was reported that C1 was not given notice of discharge and was asked to leave prior to notice being submitted. 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, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: 306000793

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

met_with: Iman Farooqui, Quality Assurance Specialist


raw_content:
Narrative:
witnessed minor smoking in the facility. Confidential interviews revealed that C1 smoked in the bathroom and bedroom and posted pictures on social media. Confidential interviews revealed C1 hid vaping devices under their clothing. Confidential interviews revealed C1 would hear staff opening doors during room checks and would hide the vaping pen next to their body when staff completed room checks. Records reviewed revealed vaping devices were found in C1's bedroom. Conflicting interviews revealed C1 was not observed smoking in the facility. The allegation that facility staff did not prevent C1 from smoking may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and appeal rights were discussed with Clete Menke, Operations Director. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On October 6, 2022, at 9:40 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Clete Menke, Operations Director of Mary's Shelter, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 07/28/2022 and no deficiencies were observed. LPA Linley interviewed six clients (C1-C6), seven staff (S1, S2), one County Social Worker (CSW1) and one County Social Worker (CSW2) was unable to be interviewed, despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: Staff Schedule, Staff Contact List, Shift Notes, Client Roster, C1's Needs and Services, C1's Special Incident Report, and C1's transition notice. On June 9, 2022, Community Care Licensing (CCL) received an allegation that facility staff did not prevent minor from smoking. It was reported that staff have suspected minor has a marijuana pen tucked in their clothing, minor posts pictures on social media smoking, and other minors have UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-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, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 10/06/2022

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


raw_content:
Narrative:
individuals, although multiple attempts were made, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff did not provide transportation to C1 in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kelli Strickland. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On August 27, 2024, at 4:12 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Kelli Strickland, After Care Director. The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Linley conducted an inspection of the facility on February 21, 2024, at 9:10 am and no deficiencies were found. LPA Linley interviewed eight staff (S1-8) and was unable to interview one client (C1), despite multiple attempts to contact them. During the investigation, the following documents were reviewed: Grocery Receipts, Menu, Staff Schedule, and Special Incident Report. On February 15, 2024, Community Care Licensing (CCL) received an allegation that staff did not provide transportation to C1 in care. It was reported that C1 ran away from staff at the doctor's office and when staff was driving back to the facility, S1 saw C1 walking, and did not pick them up and take them back to the facility. Confidential interviews revealed conflicting statements. Due to being unable to interview all UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 08/27/2024

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

met_with: Kelli Strickland


raw_content:
Narrative:
stations in the facility and there are extra diapers stored in the garage. Some interviews indicated C1 requested a specific formula brand for their child and C1 was given formula by staff. Other interviews indicated the brand of formula was in short supply and the facility provided another brand of formula. There was not a specific date provided for when C1 requested the specific brand of diapers or formula. It was also reported that C1 left personal belongings in the bathroom, staff threw C1's belongings out, and S1 yelled at C1. Confidential interviews provided conflicting statements. Some interviews indicated staff asked C1 to clean up their hygiene items in the bathroom and C1 refused, so staff bagged the items in a trash bag and set it aside, and the trash bag was thrown away. Confidential interviews indicated staff was unaware the trash bag was thrown away and once staff became aware, staff was able to retrieve the bag from the trash and gave C1's items back to them. Some interviews indicated S1 was frustrated when C1 yelled at them and walked away from talking to C1. Other confidential interviews denied S1 yelled at C1 and could not recall what S1 said to C1. Thus, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff are not allowing C1 to have access to their personal belongings while in care, staff are not safeguarding C1's personal belongings while in care, and S1 antagonize C1 in care, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Kelli Strickland. A copy of this report will be placed in the facility file.

Investigation Findings:
13On February 24, at 12:15 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kelli Strickland, After-Care Director, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on November 25, 2024, at 4:20 pm, and no deficiencies were observed. LPA Linley interviewed three Clients (C1-3) and eight Staff (S1-8). The following documents were reviewed during the investigation: facility documents. On November 22, 2024, Community Care Licensing (CCL) received allegations that staff are not allowing minor to have access to their personal belongings while in care, staff are not safeguarding minor's personal belongings while in care, and staff antagonize minor in care. It was reported that C1 was not allowed to have access to their diapers and formula when they needed them. Confidential interviews revealed conflicting statements. Some interviews indicated C1 requested a specific brand of diapers, and it is unknown if C1 received the specific brand of diapers. Other interviews indicated there are diapers provided at the changing UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 02/24/2025

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews the allegation that S1 did not treat C1 with respect is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the Interim Licensing Standards STRTP 87072(c)(15) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were emailed to the Facility Administrator, due to printer difficulties. A copy of this report will be placed in the facility file.

Investigation Findings:
13On June 19, 2025, at 12:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Kelli Strickland, Clinical Supervisor and Derrick Perry, VIce President of Operations, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on March 26, 2025, at 10:05 am. No deficiencies were observed. LPA interviewed one Client (C1) and four Staff (S1-4). LPA reviewed the facility documents. On March 20, 2025, Community Care Licensing (CCL) received an allegation that staff did not treat minor with respect. It was reported that C1 was frustrated about the air conditioner being turned off and on throughout the night and went to the living room to turn off the air conditioner at which time S1 and C1 had an exchange of words, which entailed foul language. Confidential interviews supported the allegation that S1 cursed back at C1. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 06/19/2025

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


raw_content:
Narrative:
confidential interviews could not confirm or deny the allegation. Based on confidential interviews and records reviewed the allegation that staff did not seek medical treatment for C1 in care which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to the facility. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 21, 2025, at 12:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kelli Strickland, After Care Director, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on April 21, 2025, at 11:05 am and no deficiencies were observed. LPA interviewed three Staff (S1-3), and LPA was unable to interview one Staff (S4), despite multiple attempts to contact them, and one Client (C1) declined to be interviewed. LPA reviewed the facility documents during the investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 07/21/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On June 17, 2021, at 9: AM Licensing Program Analyst (LPA) Jesus Cervantes and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual/post licensing inspection. The facility converted from a Group Home to a Provisional STRTP (Short Term Therapeutic Program) on June 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPAs toured the facility inside and out at 9: AM. The facility is a one-story residence with six bedrooms and one communal bathroom for the clients. The bedrooms are arranged so that there are two clients sharing a room and one infant. There is adequate closet and drawer space for client's belongings. The bathrooms were clean and in good repair. The hot water was tested at 9: AM and registered at 112.6 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable. There are no guns or weapons in the facility as stated by the Operations Director. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Manager, one Program Coordinator, one Staff Manager, one Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Clinical Director, one STRTP Clinician, one Social Worker, two Case Managers, and 30 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received written and verbal Medi-Cal approval. Per Facility Director, Clete Menke, official documentation of that approval has not been received. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 11: AM, LPA reviewed a sample of five clients files during the time of inspection. All files contained the required documentation per Title Regulations. At 11: AM, LPA reviewed sample of five staff files. All the staff have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Two facility staff were interviewed during the inspection. Two clients were interviewed during the inspection. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. Based on the facility inspection and files reviewed on this date, there are no deficiencies found at this time. Note: The annual for Mary's Shelter 2 (#300613291) was also conducted during the time of this inspection. An exit interview was conducted, and a copy of this report was provided to the Administrator.

met_with: Clete Menke


summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above at 3:15 pm, Licensing Program Analyst (LPA) Charmaine Linley met with Residential Program Manager, Christie Anderson, for a case management inspection. On April 15, 2026, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to conduct interviews for a complaint investigation. During record review, LPA observed there was a Special Incident Report for C1 dated 04/05/2026, that listed the initials of another client, however, the report did not provide the client's name or date of birth. LPA reviewed the client roster and asked S2 for the name of the client and S2 confirmed the individual was C3. LPA asked S2 if the facility completed a Special Incident Report for C3 and submitted it to CCL and S2 said they were not sure and would follow up with S1. On April 22, 2026, LPA returned to the facility to conduct interviews for a complaint investigation and confirmed CCL had not received the Special Incident Report for C3. LPA asked S2 if they had talked to S1 to see if the Special Incident Report had been submitted to CCL and S2 said S1 was not working today and was not able to confirm if the Special Incident Report was submitted to CCL. LPA reminded S2 to email the Special Incident Report to CCL. As of April 28, 2026, CCL has not received a Special Incident Report for C3 being involved in a physical altercation with C1 and C1's subsequent arrest. LPA Linley stressed the importance of reporting incidents in a timely manner. This process is necessary to ensure the welfare of all residents that are in care. The agency is in violation of regulation Title 22, Division 6, Chapter 1, Article Regulations 80061(b)(E) Reporting Requirements. Please refer to LIC 809-D for detailed deficiency information. An exit interview was conducted with Christie Anderson. A copy of this report and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file.

met_with: Christie Anderson


raw_content:
Narrative:
watch the children of clients that are over the age of 18. While other interviews indicated, this is a case by case decision for nonminor dependents taking their children with them to the Emergency Room or allowing staff to supervise them. Records reviewed indicated that the facility does not have documentation of a policy regarding supervising the children of nonminor dependents. Thus, confidential interviews and records reviewed could not prove or disprove the allegation. Based on confidential interviews and records reviewed, the allegation that staff refused to supervise child in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted with Christie Anderson. A copy of this report and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 28, 2026, at 4:15 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Residential Program Manager, Christie Anderson, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on April 15, 2026, at 4:00 pm and no deficiencies were observed. LPA interviewed one Client (C1), six Staff (S1-6), and LPA was unable to interview one Staff (S7), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On April 7, 2026, Community Care Licensing (CCL) received an allegation that staff refused to supervise child in care. It was reported that C1 did not feel well and asked staff to watch their child while they went to the Emergency Room and staff refused to supervise their child. Confidential interviews indicated that staff offered to drop off C1 at the Emergency Room, however, C1 would have to take their child with them because they are over the age of 18. Some confidential interviews, indicated the facility has a policy not to UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 04/28/2026

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


raw_content:
Narrative:
pieces that were supposed to fit together and did not fit together, which caused the bed to be lopsided and the facility replaced the bed frame. Confidential interviews could not confirm the linens were checked before C1 began using the bed. Based on LPA's observation, the mattress pad in bedroom #3 had two stains. Based on confidential interviews, the allegation that staff does not ensure bed is maintained in good repair; equipped with good springs and a clean mattress for client in care is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of Interim Licensing Standards STRTP 87088(c)(2) Fixtures, Furniture, Equipment, and Supplies. Facility was issued a civil penalty of $250.00 for repeat violation of Interim Licensing Standards STRTP 87088(c)(2) Fixtures, Furniture, Equipment, and Supplies. Refer to LIC 809-D. An exit interview was conducted with Christie Anderson. A copy of this report, LIC 811, and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file. to conflicting statements. However, confidential interviews and documents reviewed indicated that on one occasion C1 was upset at C3, approached C3 and S6 in an office and there was a verbal exchange. S3 and S6 stood between C1 and C3 and redirected C1, however, C1 was able to make physical contact with C3, S3, and S6 with a cord. Due to LPA being unable to interview all individuals, no specific details for the verbal altercations and conflicting statements, LPA was not able to obtain a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that Staff did not prevent altercations between youth , which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted with Christie Anderson. A copy of this report and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 28, 2026, at 3:40 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Residential Program Manager, Christie Anderson, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on April 15, 2026, at 2:40 pm and LPA observed two stains on the mattress pad in bedroom #3. LPA interviewed two Clients (C2-3), nine Staff (S1-8, S10), and LPA was unable to interview one Client (C1) and LPA was unable to interview three Staff (S9, S11, S12), despite multiple attempts to contact them. LPA reviewed the facility documents. On April 9, 2026, Community Care Licensing (CCL) received an allegation that staff does not ensure bed is maintained in good repair; equipped with good springs and a clean mattress for client in care. It was reported that C1's mattress was leaning over and the mattress did not have good springs causing C1's back to hurt. Confidential interviews indicated that staff checked the bed frame under C1's bed and observed there were SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 04/28/2026

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


facility_name: MARY'S SHELTER - HOUSE 2

summary: Facility Evaluation

raw_content:
Narrative:
On June 17, 2021, at 9: AM Licensing Program Analyst (LPA) Jesus Cervantes and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual/post licensing inspection. The facility converted from a Group Home to a Provisional STRTP (Short Term Therapeutic Program) on June 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPAs toured the facility inside and out at 10: AM. The facility is a one-story residence with five bedrooms and two bathrooms for the clients. Four bedrooms are arranged so that there is one client and their infant in a room. One bedroom is arranged so that there are two clients' sharing a room and two infants. There is adequate closet and drawer space for client's belongings. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. The bathrooms were clean and in good repair. The hot water was tested at 10: AM and registered at 115.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. There are no guns or weapons in the facility as stated by the Operations Director. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet next to the toddler play area. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Manager, one Program Coordinator, one Staff Manager, a Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Clinical Director, one STRTP Clinician, one Social Worker, two Case Managers, and 30 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received written and verbal Medi-Cal approval. Per Facility Director, Clete Menke official documentation of that approval has not been received. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 11: AM, LPA reviewed a sample of five clients files during the time of inspection. All files contained the required documentation per Title Regulations. At 11: AM, LPA reviewed sample of five staff files. All the staff have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Two facility staff were interviewed during the inspection. Three clients declined to be interviewed. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. Based on the facility inspection and files reviewed on this date, there are no deficiencies found at this time. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection. An exit interview was conducted and a copy of this report was provided to the Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2021, at 10: AM, Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual licensing inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on December 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPA toured the facility inside and out at 12: PM. The facility is a one-story residence with five bedrooms and two bathrooms for the clients. Four bedrooms are arranged so that there is one client and their infant in a room. One bedroom is arranged so that there is one client in a room and two infants. There is adequate closet and drawer space for client's belongings. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. The bathrooms were clean and in good repair. The hot water was tested at 12: PM and registered at 115.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. There are no guns or weapons in the facility as stated by the Operations Director. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet next to the toddler play area. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Director, one Staff Manager, one Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Head of Service, two Clinician, two Case Managers, two Mental Health Counselors, and 23 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received Medi-Cal approval on April 29, 2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Physical Plant, Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, and Core Therapeutic Services. Due to time constraints and the need to conduct client/staff file reviews and staff/client interviews, LPA will return at a later time to complete the annual inspection. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to the Operations Director. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on November 17, 2021. LPA met with Facility Director, Clete Menke. At 9: AM, LPA began to review a sample of ten staff files during the time of inspection. All ten staff files have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Five of five facility staff were interviewed during the inspection. Due to the need to conduct additional client interviews, and continue client file reviews, this inspection will need to be continued at later date. Based on the facility inspection, staff interviews, and files reviewed on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Facility Director, Clete Menke.. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 19, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on November 17, 2021. LPA met with Facility Director, Clete Menke. All the client files are stored and locked in the file cabinet in the staff office. At 9: AM, LPA reviewed a sample of five clients files during the time of inspection. All files contained the required documentation per Title Regulations. Two clients were interviewed during the inspection. Based on the facility inspection, client interviews, and client files reviewed on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Facility Director, Clete Menke. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2023, at 08:55 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced annual random inspection at Short Term Therapeutic Program facility. LPA was met with Facility Coordinator, Kathy McGinty. LPA toured the facility inside and out. The facility is a one-story residence with five bedrooms and two communal bathrooms for the clients. The bedrooms are arranged so that there is one client and one infant in each of the bedrooms. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested and registered at 110.4 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable. There are no guns or weapons in the facility as stated by the Operations Director. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. There are no guns or weapons in the facility as stated by the Facility Coordinator. Client's medications were observed to be inaccessible and stored inside a double locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPA observed a minimum seven-day non-perishable and a two-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. Continued on page On November 07, 2023, LPA reviewed six client files and all the files had the required documents per Title Regulations. LPA reviewed six personnel records/files. Staff have Criminal Background and Child Abuse Clearances which are complete. All the staff have met the training and qualifications per Title Regulations The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Kathy Mcginty.

met_with: Kathy McGinty


summary: Facility Evaluation

raw_content:
Narrative:
The purpose of this LIC 809 continuation form was so that Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera can attach the inspection tool form used to complete the annual inspection. Due to FAS technical difficulties the care tools did not attach correctly.


summary: Facility Evaluation

raw_content:
Narrative:
On November 8, 2024, at 2:00 pm, Licensing Program Analyst (LPA) Charmaine Linley, conducted an unannounced annual random inspection at the Short Term Therapeutic Program facility. LPA met with Vanessa McGinty, Facility Coordinator and Jill Dominguez, Facility Administrator, and toured the facility with Vanessa McGinty. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. The facility is a one-story residence with five bedrooms and two communal bathrooms for the clients. The bedrooms are arranged so that there is one client and infant in each of the bedrooms. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested and registered at 109 degrees at 10:09 am, which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum 7-day non-perishable and 2-day perishable supply of food. The hot water was tested and registered at 111 degrees at 11:11 am, which is within the appropriate range of 105 degrees to 120 degrees. There are no guns or weapons in the facility as stated by the Facility Administrator. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a double locked cabinet in the medication office. There is one camera at the facility located on the wall in the kitchen/living room area. The *** facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. All client files are stored and locked in the medication office. LPA reviewed four client (C1-4) files to ensure clients had all required documents per Title 22. LPA interviewed two clients. LPA reviewed five staff (S1-5) files and interviewed four staff. All staff met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging the child abuse reporting requirements. The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Jill Dominguez. LPA requested copies of an updated LIC 500 and LIC 308 to be emailed to LPA. A copy of this report will be placed in the facility file.

met_with: Jill Dominguez


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 08/21/25, at 9: AM, Licensing Program Analysts (LPA) Gilbert Marquez and Stefanie Mutialu met with Derrick Perry, Vice President of Operations for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve five ambulatory clients ages 12-21 years old and six infants 0-24 months. The current census is four clients. The facility is current with licensing fees. The facility is a single-story dwelling. A physical plant inspection was completed with Kathy McGinty, Facility Coordinator, which included the following checks: five bedrooms and two communal bathrooms for the clients, kitchen, medication room, dining room, living room, one staff office, playroom for the infants, therapy room, and outdoor living space. One bedroom is approved for two infants; all other bedrooms are approved for one infant. All beds were observed with appropriate bedding and mattress in good repair. Bedrooms contained adequate drawers and closet space. The water temperature was tested in client bathroom #2 which measured 115.3 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. There is one camera at the facility located on the wall in the kitchen/living room area. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in medication room. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were **continued on LIC809C** **continued from LIC809** tested and observed to be in working order; fire extinguishers are properly charged and serviced. The Facility maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. During the inspection, LPA observed staff S4 change the diaper of a client's baby on a marble counter. The facility is receiving a type B violation. LPA also asked staff S5 if any of the babies were more than 24 months. S5 stated that one was 28 months old. The facility is receiving a type B violation. Medication Records of four clients out of four (C1 - C4) were reviewed with Vanessa Ruiz, Residential Staff Manager. Per facility staff, no firearms or weapons are allowed in the facility. Due to time constraints, LPAs will return on another day to conduct client and staff interviews, and review files for clients and staff. Based on LPA's observation of a staff changing a baby that was not on the floor or using a changing table, the facility is receiving a type B violation. This is not in compliance with Interim Licensing Standards Section 87096.77(d) Personnel Services. Based on LPA review of client roster and short interview with a staff stating that a baby was over 24 months old, the facility is receiving a type B violation. This is not in compliance with California Code of Regulations, Title 22, Division Section 80010(a) Limitations on Capacity and Ambulatory Status. An exit interview was conducted to explain the facility evaluation report, along with LIC809D page, the Confidential Names List LIC811, the plan of corrections, and the appeal rights were given to Licensee, and additionally will be kept in the facility file.

Deficiencies:
87096.77(d): Personal Services

(d) Staff shall diaper each infant on a changing table, or on a changing pad placed on the floor, which meets the following specifications


summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above at 4:00 pm, Licensing Program Analyst (LPA) Charmaine Linley met with Senior Residential Counselor, Hillary Aquino, for a case management inspection. On January 26, 2026, LPA conducted an inspection of the facility and observed that bedroom #3 did not have sheets on the twin sized bed and had cereal and crackers on the floor and LPA observed bedroom #1 had a toddler bed that had a mattress pad, however, did not have a bottom sheet, top sheet, and/or blanket on the toddler bed. Based on LPA's observation, the facility is being cited for violation of Interim Licensing Standards STRTP 87088(c)(2) Fixtures, Furniture, Equipment, and Supplies and Title Regulations 80087(a) Buildings and Grounds. Please refer to LIC 809-D for detailed deficiency information. An exit interview was conducted. A copy of this report and appeal rights were provided to Hillary Aquino. A copy of this report will be placed in the facility file.

met_with: Hillary Aquino


raw_content:
Narrative:
good repair and facility carpets are not clean and in good repair and staff are not following proper reporting requirements. It was reported that the springs were exposed on the clients mattress. Confidential interviews indicated C1 told S20 their mattress was hurting their back and the mattress was replaced; however, the specific date could not be confirmed. LPA observed that bedroom #3 had a stained mattress pad and stains on the twin size mattress, room #4 and room #5 had stained mattress pads and stains on the mattresses. LPA observed that the hallway carpet had three stains near the hygiene closet. Lastly, the allegation that staff are not following reporting requirements, it was reported that C1 and C2 hit their child with a sandal and staff did not contact the Child Abuse Reporting Hotline. Confidential interviews and records reviewed, indicated there was an electronic message sent out to different staff members that stated a staff observed C1 and C2 hit their children with a sandal and asked if the information needed to be reported as abuse. Confidential interviews and records reviewed indicated the facility did not contact the Child Abuse Reporting Hotline or submit an incident report. Based on confidential interviews and record review the allegations that facility mattresses are not in good repair, facility carpets are not clean and in good repair and staff are not following proper reporting requirement are substantiated. The preponderance of evidence standards has been met. The facility is cited for violations of Interim Licensing Standards STRTP Fixtures, Furniture, Equipment, and Supplies 87088(c)(1), and Interim Licensing Standards Minor and Nonminor Dependent Parent Program Sanitation Requirements 87097.781(b)(2), and Title Division Chapter Reporting Requirements 80061(b) An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file. youths in care with dignity and respect. It was reported that staff make faces at the clients and makes other clients cry. Confidential interviews indicated conflicting statements. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff does not treat youths in care with dignity and respect, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 22, 2026, at 12:45 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Residential Program Manager, Christie Anderson, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on January 14, 2026, at 3:15 pm and LPA observed three stains on the hallway carpet near the hygiene closet, the sliding door to the dining room did not have a screen door, bedroom #3's ceiling fan was not able to be turned on and had a stained mattress pad and stains on the twin size mattress, room #4 and room #5 had stained mattress pads and stains on the mattresses. LPA interviewed three Clients (C1-3), fifteen Staff (S1-7, S9-14, S17, S20), and LPA was unable to interview three Staff (S7, S15, S16), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On January 9, 2026, Community Care Licensing (CCL) received allegations that facility mattresses are not in SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 2FACILITY NUMBER: VISIT DATE: 04/22/2026

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