raw_content:
Narrative:
LPA obtained evidence that proper supervision was implemented to care the needs of children in placement. Photos of ample food supply was available and receipts to confirm purchased various food items. LPA obtained evidence Special Incident Reports to confirm that the child was indeed accompanied to an emergency medical facility to be treated for the injury sustained to her tooth. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has determined that the allegation of Neglect/Lack of Supervision and Personal Right are deemed to be unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 3.

Investigation Findings:
13On April 27, 2022 at 11:00AM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to the PACIFIC LODGE CAMPUS STRTP to conclude the investigation and to deliver the finding. During the investigation, LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the child's involved in the incident. Information and records obtained revealed that there were no statements or documented evidence to support that the allegations that the facility "Food service is inadequate; staff did not supervise the resident, resulting in resident sustaining a broken tooth; Staff are not providing assistance with medications; staff do not supervise the residents adequately and Medical care is not provided when needed", occurred. The internal Investigation revealed that no evidence to support the allegations Neglect and Lack of Supervision and Personal Rights were violated. LPA obtained statements and records that the child had major difficulty adjusting to placement; did not engage in her program and was detained. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: PACIFIC LODGE CAMPUSFACILITY NUMBER: VISIT DATE: 04/27/2022

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


state: CA

facility_name: PACIFIC LODGE CAMPUS

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
The Department has determined that the allegation of Neglect/Lack of Supervision are deemed to be unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 3. An it interview was conducted in person and the report was provided to the Program Supervisor on 05/20/2022

Investigation Findings:
13On May 20, 2022, at 2:00PM Licensing Program Analyst (LPA) Rosslyn Gray concluded the investigation. During the investigation, there were not documented evidence to support that the allegations that "Lack of supervision resulted in group home minor physically assaulting another group home minor". LPA confirmed that a Special Incident Report (SIR) was written in a timely manner. It was determined that staff involved took the necessary steps to intervene. Staff also prevented a personal rights violation by honoring C1's request and remaining unbiased in the decision to press charges against C2. The LIC 500 confirmed that staff met ratio and was present to provide supervision. All available parties involved including law enforcement were congruent with the outcome of the investigation. The STRTP was temporaly closed on May 20, 2021. Based on the interviews conducted, the above allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: PACIFIC LODGE CAMPUSFACILITY NUMBER: VISIT DATE: 05/20/2022

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

report_type: Complaint Investigation

met_with: Program Director

complaint_status: unsubstantiated


raw_content:
Narrative:
Based on confidential statements, the allegation cannot be substantiated due to a lack of corroborating evidence. Confidential statements, record review and file history produced inconsistencies; therefore, the allegation of sexual abuse towards C1 is determined Unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited per California Code of Regulations, Title 22 at this time. Exit interview completed. A copy of this report and LIC811 was provided to Facility Administrator.

Investigation Findings:
13On April 20, 2023, at 3: PM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection to deliver findings concerning the above-mentioned allegation. LPA met with Ken Garcia, Administrator to discuss the outcome. The investigation was referred and conducted by LPA Martin and Community Care Licensing Investigations Bureau. On March 2, 2023, the El Segundo Children's Residential Program Regional Office received a complaint referral alleging sexual abuse towards Client #1 (C1) who was reportedly sexually assaulted, while in care [see Confidential Names form, LIC 811, dated 4/20/2023]. On March 7, 2023, LPA Martin met with Facility Administrator and obtained pertinent information. The investigation further consists of review of client file, review of associated report from the Department of Children and Family Services and confidential interviews with related parties including, but not limited to, C1 and assigned Social Worker. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: PACIFIC LODGE CAMPUSFACILITY NUMBER: VISIT DATE: 04/20/2023

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

met_with: Ken Garcia, Administrator


raw_content:
Narrative:
The investigation included review of facility file, client file history, related incident report, staff file records, related reports from the Los Angeles Department of Children and Family Services and the Los Angeles Police Department as well as confidential interviews and contacts with Y1, S1, and three staff members. The investigation revealed on 08/22/2023, Y1 accused S1 of inappropriately touching their buttocks area. Confidential statements and records reviewed indicate a lack of evidence to substantiate the alleged. Statements obtained from parties interviewed by the Los Angeles Police Department, the Department of Children and Family Services and CCLD Investigator were inconsistent as to the date, time, and location of said incident. Review of staff file history and confidential interviews found no witnesses to corroborate S1 inappropriately touching Y! or displaying any sexual misconduct. Based on the statements gathered, and records reviewed the Department has determined there is not enough evidence to support the allegation of Sexual Abuse; therefore, the finding is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies per California Code of Regulations or Interim Licensing Standards (ILS) cited at this time. Exit interview completed. A copy of this report and LIC811 was provided to Facility Representative.

Investigation Findings:
13On January 31, 2024, at 1: PM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection to deliver findings concerning the above-mentioned allegation. LPA Martin met with Facility Manager, to discuss the investigative outcome. On August 23, 2023, Community Care Licensing Division (CCLD) received a complaint alleging that Staff member #1 (S1) sexually touched Youth #1 (Y1) while in care (see LIC811, dated 1/31/2024). The investigation was conducted by CCLD Investigations Branch, Investigator Philippe Ryan Miles. On August 28, 2023, LPA Martin met with facility representative, informed of investigation, and obtained records. On August 24, 2023, the facility filed an incident report reporting an allegation of sexual abuse by a staff member (S1) towards a youth (Y1). Staff #1 was released from their position until further investigation. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: PACIFIC LODGE CAMPUSFACILITY NUMBER: VISIT DATE: 01/31/2024

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

met_with: Venesha Acosta, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021 at 11: AM (LPA) Licensing Program Analyst Rosslyn Gray made an unannounced visit to PACIFIC LODGE CAMPUS- STRTP for the purpose to conduct Annual Required facility inspection. LPA met with the Staff#1 (S1) Administrator of the (STRTP) SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM who granted access to the facility. The entire physical plant was inspected. The facility is currently licensed to provide care and supervision for 35 clients ages 13-17 years Ambulatory Only. Currently there are no children residing in the STRTP cottage and no staff working in the cottage the recent Temporary closure of the STRTP May 20, 2021 "due to staffing issues and renovation". All children have been transferred to the Eagle Rock STRTP and Penny Lane". S1 states that there is no weapons or guns on the premises. There is a swimming pool and on the premises; located mid campus by the AC gym. The Neimeyer Cottage: Has nine (9) bedrooms and occupies two clients and two (2) twin size beds in each room. Bedrooms #1- Bedroom # Bedroom # Bedroom # Bedroom # Bedroom # Bedroom 7 #8, and Bedroom # Currently there are No children occupying the rooms. There are two (2) twin size beds in each room.; adequate shelf space, closet space and lighting, comfortable mattress. The beds have been stripped down to the mattress due to being unoccupied. The clean linen, blankets and pillows are stored in the linen closet located in the Hallway BATHROOMS: The staff bathroom is adjacent to the community bathroom, located outside of the bedroom's mid hallway. The community bathroom is equipped with a four (4) showers, four (4) toilets and a four (4) sinks. There are two windows with blinds and screens that were observed to be in good condition. The Hot water is also is temporarily shut off due the renovation. LPA confirmed that the water works in the kitchen, bathrooms, sinks and ensured that all toilets flushed. The laundry room is located near bedroom #3, equip with a washer and dryer unit. S1 confirmed when clients are present the laundry detergent is distributed to children individually according to the load of their laundry. Due to the Temporary Closure, currently all posting requirements (i. e The Clients Personal Rights; Emergency Plan, weekly menu, etc.) are not posted; however, S1 displayed were they are stored and ready to be posted when the cottage is cleared to reopen. There is a private room located adjacent from the kitchen dining area that is utilized for the children to make phones calls. The Phone Call Log and the children's records are kept in the staff office. Although the cottage is Temporarily Closed LPA observed LPA observed ample stored hygiene supplies and feminine products. Sofas, a large chair and a book shelf was observed in the Living room/TV room. The cottage kitchen is not utilized to cook food and all meals are delivered to each cottage from the facility Dining Hall; snacks are also distributed from the Dining Hall to the staff office 3 times a day to the residents. Sharp knives and hazardous solutions are not accessible to residents. The smoke detectors operated on a connected system and Carbon Monoxide detectors are operational but are temporarily shut off. LPA observed five (5) fully charged Fire Extinguishers stored and ready to be placed in the cottage. The First aid kits are available, located in staff and nursing office. LPA observed them to be in compliance with all items and ready to be utilized. All trash cans are covered with lids are stored away ready to be utilized. S1 confirmed that when the youth are present an assigned staff "Youth Care Counselor "transports clients to local recreational facilities. Activities were previously restricted due to the rules of the CDC COVID- Guidelines. The facility will resume outside extracurricular activities and social events when the temporary closure is lifted. Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 3, there were no deficiencies cited at the time of this inspection. LPA-Gray concluded the Inspection and a copy of this report will left with the Administrator on 06/22/202.

report_type: Facility Evaluation

visit_type: Annual

met_with: Staff #1


summary: Facility Evaluation

raw_content:
Narrative:
On September 2, 2021 at 10:00AM LPA-Licensing Program Analyst Rosslyn Gray conducted a Case management licensee Initiated at PACIFIC LODGE CAMPUS- STRTP. The purpose of the inspection is due to the Licensee request for Capacity Decrease from 35 to 16. Prior to the Inspection LPA ensured that all required forms were obtained, which also included the fee and the Fire Clearance. LPA met with the Staff#1 (S1) Director of the (STRTP) SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM who provided tour of the Neimeyer Cottage. The facility is currently licensed to provide care and supervision for 16 clients ages 13-17 years Ambulatory Only. There are currently No children residing in the STRTP due to Temporary Closer May 28, 2021. The Neimeyer Cottage is currently under construction. LPA confirmed with the Maintenance Manager that the expectation of the completion is approximately 2 months (i.e painting and installing new blinds in the kitchen. There are a total of nine (9) bedrooms, eight (8) bedrooms are equipped with two (2) twin size beds in each room. The ninth (9) bedroom will be utilized in the event of a emergency and or crisis situation; it is equipped with one (1) twin size bed, a walk in closet and a desk. The Director will ensure to inform LPA when the 9th room is being utilized and an (SIR) Special Incident Report will be documented and submitted. Bedroom #1: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #2: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #3: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #4: Currently unoccupied. This bedroom will be utilized in the event of a Emergency and or Crisis situation. It last bedroom located on the right side at the end of the hallway. It is equipped with one (1) twin size bed, a walk in closet and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #5: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #6: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #7: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #8: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. Bedroom #9: Currently unoccupied. Is prepared to be occupied by two (2) clients. There are two (2) twin size beds, comfortable mattresses, lean linen, blankets and pillows. There are two (2) separate walk in closets and a two (2) desk mounted in the wall. There is adequate lighting (ceiling), and the windows are slide locked with vertical blinds; observed to be in good condition. BATHROOMS: The community bathroom is located down the outside of the bedroom in the hallway. The bathroom is equip with a four (4)showers, four (4) toilets and a four (4) sinks. There are two (2) windows with blinds that were observed to be in good condition. LPA tested the water temperature in the bathroom sinks and showers. The water drained and all toilets flushed. The laundry room is located near bedroom #3, equip with a washer and dryer unit. The laundry detergent is locked in a locked supply room and will distributed to the clients individually according to the load of their laundry. All posting requirements and Emergency Plan were met. Children will are accorded personal rights. The facility current License, Mental Health Certification; Ombudsperson for Youth in STRPs; Grievances and Personal Rights; are posted on the wall in the cottage dining area. Children are not restricted to make base on the profile list for approved phone calls. There is a private room available for the clients to make phones calls and the Phone Call Log is kept in the staff office. The Needs and Services plans will be kept in the therapist office. LPA observed ample stored hygiene supplies and feminine products stored in a locked closet. The common area is equip with adequate furniture; two (2) sofas, book shelf due to renovation additional furniture (i.e table, television). The cottage kitchen is not being utilized to cook food. There is a Non operable gas stove (shut off) with the burners and all nobs removed. The refrigerator was remove during the renovation and will be re-installed to store non-perishable foods. There is a dining table with six (6) chairs. Snacks are also distributed from the Dining Hall to cottage staff. Clients will have access to snack including fresh fruit inside the cottage. The main course of meal are served in the Dining Hall 3 times a day. Clients are escorted to and from the Dining Hall, and monitored by Youth Care Counselors. The Weekly Menu/ Daily Meals are posted in the main Dining Hall and on the kitchen wall inside the cottage. The LPA walked over to the main Dining Hall to observed the weekly menu posted; ample dining tables, refrigerators, freezers; and gas operated kitchens stoves. The sharp knives and hazardous solutions are inaccessible to clients and stored in the main Dining Hall. The smoke detectors operated on a connected system and Carbon Monoxide detectors are operational in both cottages. LPA observed four (4) fully charged fire extinguishers located in the kitchen and hallways. The First Aid Kits was in compliance with all required items; is located in the staff office. LPA observed trash cans are covered with a lids in the kitchen, bathrooms and bedroom. There is a gym; activity room, art, basketball court, baseball diamond, a music studio, recreational activities. LPA observed bodies of water(8 feet pool) that meets regulations; all staff have keys, and trained in water safety certificates and monitor the clients swimming. The Youth Care Counselor transport clients to outside recreational activities. The facility provides a activity calendar for clients to view. Activities included going to the movie theaters, Go-carting, Miniature Golf, museums etc. Some outside extracurricular activities and social events that take persons into public or crowded places have been restricted. Alternate activities have been implemented based the compliance of the client. There were no deficiencies cited at the time of this inspection. LPA-Gray concluded the inspection and a copy of this report was left at the facility with the Director of STRTP on 09/02/2021.

visit_type: Case Management

met_with: STRTP DIRECTOR


summary: Facility Evaluation

raw_content:
Narrative:
On May 5, 2022, at 11: AM Licensing Program Analyst (LPA), Rosslyn Gray and Licensing Program Manager (LPM), JoAunne Griffin conducted a Case Management Licensee Initiated inspection. The purpose of the inspection is to identify Clark Cottage and Sauble Cottage, as the Short Term Residential Therapeutic Program (STRTP). LPA met with Maria Bhattachan, Chief Administrative Officer (S1) and Ken Garcia, Administrator who granted access to the facility. The entire physical plant was inspected. The facility is currently licensed to provide care and supervision for 16 clients ages 13-17 years old. Currently no children are residing in the STRTP due to temporary closer effective May 28, 2021. Each cottage will have a capacity of 8 clients. There is a pool on the premises that meets regulations. LPA observed pool surrounded by 5-foot self-latching gate that meets regulations; all staff have keys, are trained in water safety, have certificates, and monitor the clients while swimming. There is a dining hall, school and a chapel located on the campus that is not being utilized. Clark Cottage and Sauble Cottage: There are no clients currently residing in cottage. The bedrooms are prepared to be occupied by one (1) client. There is one (1) twin size bed, comfortable mattresses, clean linen, blankets, and pillows. There are two (2) separate walk-in closets and one (1) desk mounted to the wall. There is adequate lighting, and the windows are observed to be in good condition. There is a storage room equipped with extra clothing, linen, and hygiene items. LPA observed ample stored hygiene supplies and feminine products stored in a locked closet. Bathrooms were observed to be clean and in working order. Continued on LIC 809-C In both cottages LPA observed, Ombudsperson for the Youth, Grievances, and a suggestion box. All required postings were posted on the wall in the dining area. Children are not restricted to make phone calls based on the approved phone calls list. There is a private room available for the clients to make phones calls and the Phone Call Log is kept in the staff office. The Needs and Services plans will be kept in the therapist office. The common area is equipped with adequate furniture; three (3) sofas, a bookshelf; furniture (i.e table, television). The kitchen is utilized to with an operable 4-burner electrical stove. The refrigerator is used to store extra snacks and non-perishable foods. There is a dining table with eight (8) chairs. The food menu is posted on the refrigerator. Clients will have access to snack including fresh fruit inside the cottage. The smoke detectors are operated on a connected system and carbon monoxide detectors are operational in both cottages. LPA observed three (3)) fully charged fire extinguishers located in the kitchen and hallways. Fire extinguishers expire May 2022. The First Aid kits are in accordance with all required items and are located in the staff offices. LPA observed that trash cans are covered with a lid in the kitchen, bathrooms, and bedroom. There is a gym, activity room, art room, basketball court, baseball diamond, music studio and recreational activities available. LPA Gray concluded the inspection, and a copy of this report was left at the facility with the S1.

met_with: Chief Compliance and Quality Improvement Officer.


summary: Facility Evaluation

raw_content:
Narrative:
On June 21, 2022 at 10: AM LPA-Licensing Program Analyst Rosslyn Gray conducted a Case management licensee Initiated at PACIFIC LODGE CAMPUS- STRTP- SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM/SAUBLE COTTAGE. The purpose of the inspection is due to the Licensee request for Reduction of Capacity from sixteen (16) to eight (8) female children. Prior to the Inspection LPA conducted a Health and safety risk assessment upon arriving at the facility. LPA ensured that all required forms were obtained. LPA met with the Staff#1 (S1) Facility Supervisor of the (STRTP) who provided tour of the SAUBLE COTTAGE. Outdoor Area: The activity space is free of hazard materials and debris. The passageways and porches are unobstructed. There is central heat and air conditioning unit. LPA observed all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. There are six (6) entrances and exits to the cottage located at the front door, Kitchen, East and West Wing hallways and two (2) exits located in the common area. There are currently six (6) Female children (Ambulatory only) residing in the SAUBLE COTTAGE. There are a total of eight (8) bedrooms, each bedroom is equipped with one (1) full size bed, a comfortable mattress, clean linen, blankets and pillows. There are two (2) separate walk in closets and one (1) desk mounted in the wall. There is adequate lighting, and the windows are slide locked, with a grey colored curtains observed to be in good condition. Bedroom #1: Currently occupied by Child #1. (Located on the East Wing of the cottage facility). Bedroom #2: Currently unoccupied. It is ready and prepared to be occupied by one (1) child. (Located on the East Wing of the cottage facility). Bedroom #3: Currently occupied by Child #2 (Located on the East Wing of the cottage facility). LIC- Page 1 of The laundry room is located to right side of at the entrance. It is equipped with a washer and dryer unit. The laundry detergent is locked and will distributed to the clients individually according to the load of their laundry. Extra supplies of and facility decorations are also stored in the laundry room. All posting requirements and Emergency Plan are posted on the wall to right of entrance; that include the facilities current License, Mental Health Certification; Ombudsperson for Youth in STRTP; Grievances and Personal Rights. Children are not restricted to make phone calls unless restricted by there authorized representative. The children are allowed make private phones from the facility phone monitored by staff and recorded on a phone log. Children are are also permitted to utilize their personal phones to make phone calls. The children's Needs and Services plans are electronically monitored by the therapist and the clinical team. LPA observed ample stored hygiene supplies and feminine products stored in a locked linen closet located in the hallway of West Wing of the facility cottage. The common area is equipped with adequate furniture, personal lockers, one (1) sofa, two (2) bing bags, book shelves, a television, a swing chair, a small chair, games, puzzles and DVD's. There is also two (2) exits. The cottage kitchen is utilized to cook food. There is a operable 4 burner electrical stove. There is a top bottom refrigerator/freezer. There additional top bottom freezer refrigerator and one (1) freezer unit is stored in a room located in the West Wing hallway. The staff cooks hot meals at night or monitor the children if they choose to cook their own meal. The snacks are made accessible for the children; including fresh fruit and frozen food items. The Weekly Menu/ Daily Meals are posted on the refrigerator on a daily basis. There is a dining table with eight (8) chairs in good condition. LPA observed apple perishable and non perishable food items. The sharp knives are locked in a cabinet in the kitchen and hazardous solutions are inaccessible to clients locked in the Mental Health office. The smoke detectors operated on a connected system and Carbon Monoxide detectors observed to be operational. LPA observed three (3) fully charged fire extinguishers located at the exit of the East and West hallway and kitchen. The First Aid Kits was in compliance with all required items and is located in the staff office. LPA observed trash cans are covered with a lids in the kitchen and bathrooms. There is a gym; activity room, art room, basketball court, baseball diamond, a music studio, recreational activities. LPA observed bodies of water(8 feet pool) that meets regulations; all staff are trained in water safety certificates and monitor the clients swimming. The Youth Care Counselor transport clients to outside recreational activities and to other appointments. LIC- Page 3 of Bedroom #4: Currently occupied by Child #3, (Located on the East Wing of the cottage. Bedroom #5: Currently unoccupied. It is ready and prepared to be occupied by one (1) child. (Located on the West Wing of the cottage facility). Bedroom #6: Currently occupied by Child #4,(Located on the West Wing of the cottage. Bedroom #7: Currently occupied by Child #5, (Located on the West Wing of the cottage. Bedroom #8: Currently occupied by Child #6, (Located on the West Wing of the cottage. LPA observed and inspected room numbers 9 through 11 are utilized for other purposes. Room #9 is identified as the staff office is located at the end of the front entrance, at the beginning of the East Wing. Room #10 is identified as the Mental Health office is located on the East Wing of the cottage adjacent bathroom #1. Room #11 is identified as the Therapist Room located on the West Wing of the cottage. There are a total of four (4) bathrooms. Bathroom #1 and Bathroom #2 are identified as the children's community bathroom, located on the East Wing and the West Wing of the facility cottage. Bathrooms #1 and #2 are equipped with a two (2)showers, two (2) toilets, three (3) sinks, and one (1) sliding window, observed to be in good condition. LPA inspected drainage and tested the water temperature in sinks, showers and the toilet flushed properly. Bathroom #3 is identified as the staff bathroom is located on the East Wing of cottage facility, equipped with one (1) toilet and (1) sink. LPA inspected drainage and tested the water temperature in the bathroom sink and the toilet flushed properly. Bathroom #4 is located inside the Therapist office located on the East Wing of cottage facility is equipped one (1) toilet and (1) sink, one (1) sliding window and a shower and tub that is not being utilized. LPA inspected and tested the water temperature in the bathroom sink and the toilet flushed properly. LIC- Page 2 of The facility provides a activity calendar for clients to view. Activities included going to the local dog park, movie theaters, Go-carting riding, Miniature Golf, museums etc. Alternate activities have been implemented based the compliance of the children. There were no deficiencies cited at the time of this inspection. LPA-Gray concluded the inspection and a copy of this report was left at the facility with the Facility Supervisor on 06/21/ LIC- Page 4 of 4

met_with: Facility Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On July 14 2023 at 9:30AM. Licensing Program Analysts (LPAs) Rosslyn Gray and Zena Phillips made an announced visit at PACIFIC LODGE CAMPUS-STRTP, to conduct the Psychotropic Case Medication Inspection. LPAs conducted a Health and safety risk assessment upon arriving at the facility. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Gray and Phillips met with Venesha K. Acosta and inspected the facility inside and out. LPAs reviewed Five (5) of child's psychotropic medications and medication records. LPAs interviewed two (2) of the children currently prescribed psychotropic medication. LPAs reviewed three (3) staff personnel files on site at the facility. LPAs interviewed three (3) of staff on site to discuss the facilities policies and procedures of operation. The Administrator provided a physical hard copy of the psychotropic medication training topics during the training for for LPA's to review. No deficiency were cited per Interim Licensing Standards for STRTP Version 4. An exit interview was conducted, and a copy of this report was left with the Administrator.

met_with: ADMINISTRATOR


summary: Facility Evaluation

raw_content:
Narrative:
On July 17, 2023 at 10:30AM (LPA) Licensing Program Analyst Rosslyn Gray made an unannounced visit to PACIFIC LODGE CAMPUS- STRTP- SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM, for the purpose of conducting an Annual/Random facility inspections. LPA-Gray met Venesha K. Acosta/ Administrator who granted access to the facility and an inspection was conducted together. Prior to the Inspection LPA conducted a Health and safety risk assessment upon arriving at the facility. S1 provided a tour of the SAUBLE COTTAGE. The facility is currently licensed to provide care and supervision for eight (8) clients ages 13-17, Ambulatory only. This facility also provided services for NONMINOR DEPENDENTS (NMD) to Pursuant of W&I CODE 16501(C)(1).There is Pool on the premises which meets Licensing Regulations. S1 confirmed that there are no firearms or weapons on the premises. There is a NAXOLONE WAIVER on File. LPA observed pool surrounded by 5-foot self-latching gate that meets regulations; all staff are trained in water safety, have certificates, and monitor the clients while swimming. Currently there are six (6) children in placement. LPA-Gray inquired about any blanket policy surrounding community passes. S1 stated that there are not blanket policy regarding community passes, that the authorized representative approve community passes for all youth and it is also discussed in the Child Family Team Meeting CFT. The STRTP SAUBLE COTTAGE is a 1 story facility located on the Pacific Lodge Campus grounds. During the inspection LPA observed the following: Outdoor Area: The activity space is free of hazard materials and debris. The passageways and porches are unobstructed. There is central heat and air conditioning unit. LPA observed all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. There are six (6) entrances and exits to the cottage located at the front door, Kitchen, East and West Wing hallways and two (2) exits located in the common area. LIC- Page 1 of There are currently six (6) Female children (Ambulatory only) residing in the SAUBLE COTTAGE. There are a total of eight (8) bedrooms, each bedroom is equipped with one (1) full size bed, a comfortable mattress, clean linen, blankets and pillows. There are two (2) separate walk in closets and one (1) desk mounted in the wall. There is adequate lighting, and the windows are slide locked, with a grey colored curtains observed to be in good condition. Bedroom #1: Currently occupied by Child #1. (Located on the East Wing of the cottage facility). Bedroom #2: Currently unoccupied. It is ready and prepared to be occupied by one (1) child. (Located on the East Wing of the cottage facility). Bedroom #3: Currently occupied by Child #2 (Located on the East Wing of the cottage facility). Bedroom #4: Currently occupied by Child #3, (Located on the East Wing of the cottage. Bedroom #5: Currently unoccupied. It is ready and prepared to be occupied by one (1) child. (Located on the West Wing of the cottage facility). Bedroom #6: Currently occupied by Child #4,(Located on the West Wing of the cottage. Bedroom #7: Currently occupied by Child #5, (Located on the West Wing of the cottage. Bedroom #8: Currently occupied by Child #6, (Located on the West Wing of the cottage. LPA observed and inspected room numbers 9 through 11 are utilized for other purposes. Room #9 is identified as the staff office is located at the end of the front entrance, at the beginning of the East Wing. Room #10 is identified as the Mental Health office is located on the East Wing of the cottage adjacent bathroom #1. Room #11 is identified as the Therapist Room located on the West Wing of the cottage. There are a total of four (4) bathrooms. LIC- Page 2 of Bathroom #1 and Bathroom #2 are identified as the children's community bathroom, located on the East Wing and the West Wing of the facility cottage. Bathrooms #1 and #2 are equipped with a two (2)showers, two (2) toilets, three (3) sinks, and one (1) sliding window, observed to be in good condition. LPA inspected drainage and tested the water temperature in sinks, showers and the toilet flushed properly. Bathroom #3 is identified as the staff bathroom is located on the East Wing of cottage facility, equipped with one (1) toilet and (1) sink. LPA inspected drainage and tested the water temperature in the bathroom sink and the toilet flushed properly. Bathroom #4 is located inside the Therapist office located on the East Wing of cottage facility is equipped one (1) toilet and (1) sink, one (1) sliding window and a shower and tub that is not being utilized. LPA inspected and tested the water temperature in the bathroom sink and the toilet flushed properly. The laundry room is located to right side of at the entrance. It is equipped with a washer and dryer unit. The laundry detergent is locked and will distributed to the clients individually according to the load of their laundry. Extra supplies of and facility decorations are also stored in the laundry room. All posting requirements and Emergency Plan are posted on the wall to right of entrance; that include the facilities current License, Mental Health Certification; Ombudsperson for Youth in STRTP; Grievances and Personal Rights. Children are not restricted to make phone calls unless restricted by there authorized representative. The children are allowed make private phones from the facility phone monitored by staff and recorded on a phone log. Children are are also permitted to utilize their personal phones to make phone calls. The children's Needs and Services plans are electronically monitored by the therapist and the clinical team. LPA observed ample stored hygiene supplies and feminine products stored in a locked linen closet located in the hallway of West Wing of the facility cottage. The common area is equipped with adequate furniture, personal lockers, one (1) sofa, two (2) bing bags, book shelves, a television, a swing chair, a small chair, games, puzzles and DVD's. There is also two (2) exits. The cottage kitchen is utilized to cook food. There is a operable 4 burner electrical stove. There is a top bottom refrigerator/freezer. There additional top bottom freezer refrigerator and one (1) freezer unit is stored in a room located in the West Wing hallway. The staff cooks hot meals at night or monitor the children if they choose to cook their own meal. The snacks are made accessible for the children; including fresh fruit and frozen food items. The Weekly Menu/ Daily Meals are posted on the refrigerator on a daily basis. There is a dining table with eight (8) chairs in good condition. LIC- Page 3 of THIS REPORT WAS AMENDED DUE TO CORRECT THE NAME OF THE ELECTRONIC PORTAL LPA observed ample perishable and non perishable food items. The sharp knives are locked in a cabinet in the kitchen and hazardous solutions are inaccessible to clients locked in the Mental Health office. The smoke detectors operated on a connected system and Carbon Monoxide detectors observed to be operational. LPA observed three (3) fully charged fire extinguishers located at the exit of the East and West hallway and kitchen. The First Aid Kits was in compliance with all required items and is located in the staff office. LPA observed trash cans are covered with a lids in the kitchen and bathrooms. There is a gym; activity room, art room, basketball court, baseball diamond, a music studio, recreational activities. LPA observed bodies of water(8 feet pool) that meets regulations; all staff are trained in water safety certificates and monitor the clients swimming. The Youth Care Counselor transport clients to outside recreational activities and to other appointments. The facility provides a activity calendar for clients to view. Activities included going to the local dog park, movie theaters, Go-carting riding, Miniature Golf, museums etc. Alternate activities have been implemented based the compliance of the children. LPA reviewed staff records with the hard in the office. LPA reviewed Clients Records with the hard and stored in the facilities and on the Exym Portal. LPA interviewed three (3) Staff. LPA obtained consent to interview five (5) clients that were present. LPA gave the clients options to have an adult staff present during the interview. There were no deficiencies cited at the time of this inspection. LPA-Gray concluded the inspection and a copy of this report was left at the facility with the Facility Supervisor on 07/17/ LIC- Page 4 of 4

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 11, 2025, at 10:30AM (LPA) Licensing Program Analyst Rosslyn Gray made an unannounced visit to PACIFIC LODGE CAMPUS- STRTP- SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM, for the purpose of conducting an Annual/Random facility inspection. LPA-Gray met Venesha K. Acosta/ Administrator and the Clinical Supervisor Karina Pineda who granted access to the facility and provided tour of the of the entire physical plant. LPA conducted a Health and safety risk assessment upon arriving at the facility. S1 provided a tour of the SAUBLE COTTAGE. The facility is currently licensed to provide care and supervision for eight (8) clients ages 13-18, Ambulatory only. This facility also provided services for NONMINOR DEPENDENTS (NMD) to Pursuant of W&I CODE 16501(C)(1). S1 confirmed that there are no firearms or weapons on the premises. There is a NAXOLONE WAIVER on File. Currently there are four (4) children in placement. LPA-Gray inquired about any blanket policy surrounding community passes. S1 stated that there is no blanket policy regarding community passes, that the authorized representative approves community passes for all clients and it is also discussed in the Child Family Team Meeting CFT. The STRTP Overview: During the inspection LPA observed the following: The STRTP SAUBLE COTTAGE is a 1-story facility located on the Pacific Lodge Campus grounds. Outdoor Area: The activity space is free of hazard materials and debris. The passageways and porches are unobstructed. LPA observed a pool surrounded by a 5-foot self-latching gate that meets regulations; all staff are trained in water safety, have certificates, and monitor the clients while swimming. LPA observed all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. LIC- Page 1 of Bathroom #1 and Bathroom #2 are identified as the children's community bathroom, located on the East Wing and the West Wing of the facility cottage. Bathrooms #1 and #2 are equipped with two (2) showers, two (2) toilets, three (3) sinks, and one (1) sliding window, observed to be in good condition. LPA inspected drainage and tested the water temperature in sinks, showers and the toilet flushed properly. Bathroom #3 is identified as the staff bathroom is located on the East Wing of cottage facility, equipped with one (1) toilet and (1) sink. LPA inspected drainage and tested the water temperature in the bathroom sink and the toilet flushed properly. Bathroom #4 is located inside the Therapist office located on the East Wing of cottage facility equipped with one (1) toilet and (1) sink, one (1) sliding window and a shower and tub that is not being utilized. LPA inspected and tested the water temperature in the bathroom sink and the toilet flushed properly. The laundry room is located to the right side of the entrance. It is equipped with a washer and dryer unit. The laundry detergent is locked and will be distributed to the clients individually according to the load of their laundry. Extra supplies of and facility decorations are also stored in the laundry room. All posting requirements and Emergency Plan are posted on the wall to the right of entrance; that include the facilities current License, Mental Health Certification; Ombudsperson for Youth in STRTP; Grievances and Personal Rights. Clients are not restricted to making phone calls unless restricted by their authorized representative. The clients are allowed to make private phones from the facility phone monitored by staff and recorded on a phone log. clients are also permitted to utilize their personal phones to make phone calls. The children's Needs and Services plans are electronically monitored by the therapist and the clinical team. LPA observed ample stored hygiene supplies and feminine products stored in a locked linen closet located in the hallway of West Wing of the facility cottage. The common area is equipped with adequate furniture, personal lockers, one (1) sofa, two (2) Bing bags, bookshelves, a television, a swing chair, a small chair, games, puzzles and DVD's. There are also two (2) exits. The cottage kitchen is utilized to cook food. There is an operable 4 burner electrical stove. There is a double door refrigerator/freezer. There is additional top bottom freezer refrigerator, and one (1) freezer unit is stored in a room located in the West Wing hallway. The staff cooks hot meals at night or monitors the clients if they choose to cook their own meals. The snacks are made accessible for the clients, including fresh fruit and frozen food items. The Weekly Menu/ Daily Meals are posted on the refrigerator daily. There is a dining table with six (6) and additional chairs are available based on the census, observed to be in good condition. LIC- Page 3 of LPA observed ample perishable and nonperishable food items. The sharp knives are locked in a cabinet in the kitchen and hazardous solutions are inaccessible to clients locked in the Mental Health office. The smoke detectors operated on a connected system and Carbon Monoxide detectors observed to be operational. Three (3) fully charged fire extinguishers are located at the exit of the East and West hallway and kitchen. The First Aid Kits was in compliance with all required items and is in the staff office. LPA observed trash cans covered with a lid in the kitchen and bathrooms. There is a gym, activity room, art room, basketball court, baseball diamond, a music studio, recreational activities. LPA observed bodies of water (8 feet pool) that meet state regulations; all staff are trained in water safety certificates and monitor the clients swimming. The Youth Care Counselor transport clients to outside recreational activities and to other appointments. The facility provides an activity calendar for clients to view. Activities included going to the local dog park, movie theaters, Go-carting riding, Miniature Golf, museums etc. Alternate activities have been implemented based on the compliance of the clients. LPA reviewed three (3) staff records via electronic files. LPA reviewed four (4) Clients Records in a binder and Clinical notes were reviewed on Exym Portal. LPA interviewed three (3) Staff. LPA obtained consent to interview four (4) clients that were present, and gave the clients the options to have an adult staff present during the interview. LPA interviewed 2 of the 4 clients wiling to be interviewed, There were no deficiencies cited at the time of this inspection. LPA-Gray concluded the inspection, and a copy of this report was left at the facility with the Administrator Venesha K. Acosta on 09/11/2025. LIC- Page 4 of There is a central heating and air conditioning unit. There are six (6) entrances and exits to the cottage located at the front door, Kitchen, East and West Wing hallways and two (2) exits located in the common area. There are currently four (4) Female clients (Ambulatory only) residing in the SAUBLE COTTAGE. There is a total of eight (8) bedrooms, each bedroom is equipped with one (1) full size bed, a comfortable mattress, clean linen, blankets and pillows. There are two (2) separate walk-in closets and one (1) desk mounted in the wall. There is adequate lighting, and the windows are slide locked, with grey colored curtains observed to be in good condition. Bedroom #1: Currently occupied by Child #4. (Located on the East Wing of the cottage facility). Bedroom #2: Currently unoccupied. It is ready and prepared to be occupied by one (1) child. (Located on the East Wing of the cottage facility). Bedroom #3: Currently unoccupied. (Located on the East Wing of the cottage facility). Bedroom #4: Currently occupied by Child #2, (Located on the East Wing of the cottage. Bedroom #5: Currently occupied by Child #3 (Located on the West Wing of the cottage facility). Bedroom #6: Currently occupied by Child #1,(Located on the West Wing of the cottage. Bedroom #7: Currently unoccupied, (Located on the West Wing of the cottage. Bedroom #8: Currently unoccupied (Located on the West Wing of the cottage. LPA observed and inspected room numbers 9 through 11 are utilized for other purposes. Room #9 is identified as the staff office is located at the end of the front entrance, at the beginning of the East Wing. Room #10 is identified as the Mental Health office located on the East Wing of the cottage adjacent bathroom #1. Room #11 is identified as the Therapist Room located on the West Wing of the cottage. There is a total of four (4) bathrooms. LIC- Page 2 of 4

met_with: Administrator Venesha K. Acosta/


facility_name: PALO VERDE HOUSE

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Additionally, during inspection on 5/4/22, LPA observed dark spots in the corners and along the seal of the shower-tub in the hallway bathroom and small, dark spots in the shower in the en suite bathroom. During today's inspection, LPA took a glove and was able to smear the spots, indicating they are not stains and are active mold/mildew. LPA inspected the facility's store of cleaning supplies and observed three cans of bathroom cleaner targeting soap scum but no cleaners for mold/mildew or mold/mildew stains. There is no evidence that spots have been treated to ensure no active mold is present. The preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. LPA is issuing two citations of California Code of Regulations (CCR), TItle 22, Section Buildings and Grounds. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Mattie Marsh, whose signature confirms receipt.

Investigation Findings:
13On 5/24/22 at 1:08PM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint inspection at the facility. LPA met with Administrator Mattie Marsh and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and pre-visit screening call. During complaint investigation, LPA inspected the facility and interviewed 4 residents and 2 staff. Based on observation and interview, 2 of 4 residents reported seeing bugs in the facility. Photos of 3 different bugs on different occasions inside the facility were sent to LPA, including at least two where bugs were found in a resident's bed. During one observation, LPA was called by a resident, and LPA could hear staff remove the bug as requested by the youth. Additionally, LPA was initially informed by the facility that the facility had a current contract with an exterminator service. However, upon request for the most recent invoice, LPA was provided with a new contract dated 5/6/22, after LPA's intial inspection on 5/4/22. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: VISIT DATE: 05/24/2022

met_with: Administrator Mattie Marsh

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. LPA is issuing three citations, per California Code of Regulations, Title 22, Section Food Services and STRTP Interim Licensing Standards (ILS), Sections Plan of Operation and Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to Administrator Mattie Marsh, whose signature on this form confirms receipt.

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 12/14/22 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at listed facility and spoke with Mattie Marsh/Patrick Davis, Administrators and Bryce Marsh, House Manager. The purpose of the inspection was to open the complaint and deliver the findings for the above complaint allegations. During investigation, interviews were conducted and documents were reviewed, and it was determined that the facility staff did not surrender valuables entrusted to them to a youth in care upon the youth's disharge and facility staff did not safeguard valuables to them. Based on LPA's interview with staff and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, facility staff did not surrender valuables entrusted to them to a youth in care upon the youth's disharge and facility staff did not safeguard valuables to them is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80026(b) Safeguards for Cash Resources, Personal Property and Valuables. At this time, one deficiency was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Mattie Marsh/Patrick Davis, Administrators and Byrce Marsh, House Manager. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

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

met_with: Mattie Marsh and Patrick Davis


raw_content:
Investigation Findings:
13On 1/9/23 and 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Palo Verde and spoke with Mattie Marsh and Patrick Davis, Administrators. The purpose of the inspection was to deliver the findings for the above complaint allegations. This complaint was taken as an assignment by Community Care Licensing's (CCL's) Investigations Branch (IB) and assigned to Inv. Blake Williams on 09/22/2022. Complaint was upgraded to a full investigation on 11/30/2022. During investigation, confidential interviews, police reports, and physical evidence were obtained, it was determined that staff did not handle resident in a rough manner and staff did not choke a resident. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that staff handles resident in a rough manner and staff choked a resident. Therefore, the above allegations are unsubstantiated. At this time, no deficiencies were cited. Exit interview was conducted and a copy of the report was left with Mattie Marsh and Patrick Davis, Administrator UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Mattie Marsh/Patrick Davis


raw_content:
Narrative:
During the course of the investigation, LPA Hood conducted seven confidential interviews. LPA reviewed the facility's program statement, incident reports, C1's Needs and Services Plan, and email correspondence. According to four confidential interviews and record review, on 4/28/2023 the facility had informed Community Care Licensing (CCL) and Butte County of a plan to temporarily close on 5/1/2023 via email. This email also documented that C1 would need to be removed from the facility on or before 5/1/2023. This temporary closure and eviction were rescinded on 4/31/2023. Based on three confidential interviews and record review, facility staff did not provide updated service plan to the authorized representative until 5/19/2023. Based on the confidential interviews and record review, the allegations that staff did not provide client's records to authorized representative and staff did not follow proper eviction procedures are substantiated. LPA delivered a Type A citation for STRTP Interim Licensing Standards 87068.4(c)(1). Facility did not provide service plan or proper communication during the eviction process which poses an immediate risk to health, safety and/or personal rights of the client in care. LPA conducted an exit interview with David Beanes, Facility Manager at 1:58PM and provided appeal rights.

Investigation Findings:
13On 6/12/2023 at 12:14PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to deliver the findings for the listed allegations. LPA met with David Beanes, Facility Manager, who informed them that they were leaving to pick up a client and nobody else was present in the home. LPA Hood attempted to call Administrator, Mattie Marsh, and Director, Patrick Davis. LPA returned to the facility at 1:45PM. LPA met with David Beanes, Facility Manager. During the course of the investigation, LPA Hood conducted seven confidential interviews. LPA reviewed the facility's program statement, incident reports, C1's Needs and Services Plan, and email correspondence. Continued on LIC9099C... SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: VISIT DATE: 06/12/2023

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

met_with: David Beanes


raw_content:
Narrative:
Based on confidential interviews, the facility had informed Community Care Licensing (CCL) of the inability to safely place C1. Based on the confidential interviews and record reviews, the allegation that facility did not follow eviction protocols may or may not be true. The allegation has not met the preponderance of doubt, and the allegation is therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with Mattie Marsh, Program Manager at 1:35PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 6/22/2023 at 12:11PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to conduct interviews and deliver the finding for the above allegation. LPA met with Mattie Marsh, Program Manager. During the course of the investigation, LPA conducted five confidential interviews. LPA reviewed the 14-day notice, pertinent incident reports, daily notes, C1's Needs and Services Plan, photographs of staff injuries, and email correspondence. Based on confidential interviews and incident report, C1 was placed on a 5150 hold by Pittsburg Police Department on 6/1/2023. Based on confidential interviews, on 6/2/2023 the facility gave notice to Butte County that they would not be able to accept C1 back from their hospitalization because of multiple staff UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: VISIT DATE: 06/22/2023

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

met_with: Mattie Marsh


raw_content:
Narrative:
continued from LIC Regarding the allegation that staff made inappropriate statement: During the course of the investigation, LPA Karkazis conducted confidential interviews with staff, clients, and conducted document research. During confidential interviews, inconsistent information was provided. Most interviewees stated that there were no inappropriate statements made, one interviewee stated there was an inappropriate statement, but could not provide details. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that staff made inappropriate statement. Therefore, the above allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Brice Marsh, House Supervisor.

Investigation Findings:
13On 9-22-23 12:47PM, Licensing Program Analyst (LPA) conducted an unannounced inspection at Palo Verde and met with Brice Marsh, House Supervisor, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. Regarding the allegation that the facility is not providing outings: During the course of the investigation, LPA Karkazis conducted confidential interviews with staff, clients, and conducted document research. During confidential interviews, most interviewees stated that outings are always provided. The frequency and type maybe changed due to certain behaviors and safety concerns. Other interviewees state activities were only provided one time per month. LPA conducted document research and found that clients had seventeen outings for June 2023. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the facility is not providing outings. Therefore, the above allegation is UNSUBSTANTIATED. continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO ASC, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: VISIT DATE: 09/22/2023

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

met_with: Brice Marsh House Supervisor


raw_content:
Investigation Findings:
13At 02:00PM on 10/23/2023, Licensing Program Analyst (LPA) Karmen Balhotra made an unannounced complaint inspection to the facility listed above for this amendment. The reason for the inspection is to deliver findings for the allegation listed above. LPA met with Brice Marsh, Supervisor who helped facilitate the inspection. Over the course of the investigation, LPA conducted confidential interviews and a file review. Evidence obtained revealed that for the allegation of, Minor inappropriately touched another minor while in care, is found to be substantiated. During confidential interviews, three of four staff members interviewed stated that a former client did inappropriately touch another client in care. Confidential interviews revealed that staff were unaware of sexualized behaviors that the client may have had and that the incident took place after clients were leaving the facility together on unauthorized absences. The facility separated clients upon learning of the incident. Therefore, per evidence obtained, the preponderance of evidence has been met. Based on today's inspection the facility is being cited under section 80072(a)(1) Personal Rights. An exit interview was conducted and a copy of this report was left with Supervisor. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Karmen Balhotra LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Brice Marsh


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Investigation Findings:
13At 12:00PM on 10/11/2023, Licensing Program Analyst (LPA) Karmen Balhotra made an unannounced complaint inspection to the facility listed above. The reason for the inspection is to deliver findings for the allegation listed above. LPA met with Brice Marsh, Supervisor who helped facilitate the inspection. Over the course of the investigation, LPA conducted confidential interviews and a file review. Evidence obtained revealed that for the allegations of; Staff do not properly supervise minors, Staff kicked minor, Staff do not prevent minors from fighting, and Staff speak inappropriately to minors, are found to be unsubstantiated. This agency has investigated the complaint alleging the allegations listed above and have found that the complaint is unsubstantiated, meaning that although the allegation may have happened, or is valid, there is not a preponderance of the evidence to prove that the allegations above occurred. Based on today's inspection, no California Code of Regulations were cited. An exit interview was conducted, and a copy of this report was left with Supervisor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Karmen Balhotra LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


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Investigation Findings:
13At 02:00PM on 10/23/2023, Licensing Program Analyst (LPA) Karmen Balhotra made an unannounced complaint inspection to the facility listed above. The reason for the inspection is to deliver findings for the allegation listed above. LPA met Brice Marsh, Supervisor who helped facilitate the inspection. Over the course of the investigation, LPA conducted confidential interviews and a file review. Evidence obtained revealed that for the allegation of, Minor inappropriately touched another minor while in care, is found to be substantiated. During confidential interviews, three of four staff members interviewed stated that a former client did inappropriately touch another client in care. Confidential interviews revealed that staff were unaware of sexualized behaviors that the client may have had and that the incident took place after clients were leaving the facility together on unauthorized absences. The facility separated clients upon learning of the incident. Therefore, per evidence obtained, the preponderance of evidence has been met. Based on today's inspection the facility is being cited under section 80072(a)(1) Personal Rights. An exit interview was conducted and a copy of this report was left with Supervisor. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Karmen Balhotra LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

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


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Narrative:
On July 24, 2023, the Department received a complaint alleging facility staff did not allow client to call social worker, staff locked client out of facility and staff reported false allegations to law enforcement. Based on confidential interviews, client was in crisis and staff tried to redirect client to base level for client to use the phone. Staff offered to dial social worker for client and was denied by client. Client continued escalated behaviors outside of facility and law enforcement was called at which time staff were told to shelter in place and lock the doors until law enforcement arrived. LPA Pavia could not obtain transcripts of the 911 call to verify staff were given the direction to lock the client outside while waiting for officers to arrive. Client was outside of the facility for no more than 15 minutes. Staff purportedly informed law enforcement that client was attempting to get a knife from the staff office, not that client tried to stab staff. Client did not have a knife in possession during this incident. Based on confidential interviews conducted, the above allegations may have happened or are valid, however, there is not a preponderance of the evidence to prove that staff did not allow client to contact social worker, or staff made false allegations to law enforcement or staff locked client out of facility without direction from law enforcement; therefore, the above allegations are unsubstantiated.

Investigation Findings:
Licensing Program Analyst (LPA) Monica Pavia conducted a complaint investigation. Licensing Program Analyst (LPA) Mariah Hawkins notified Palo Verde House of new complaint allegations, on July 28, 2023, at 4:30pm. LPA Hawkins obtained copies of relevant facility, personnel, and resident records. Confidential interviews were conducted, as a part of this investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Monica Pavia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: VISIT DATE: 11/08/2023

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

met_with: Tony Beane


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Investigation Findings:
13At 04:30pm on 01/24/2024, Licensing Program Analyst (LPA) Karmen Balhotra made an unannounced complaint inspection to the facility listed above. The reason for the inspection is to deliver findings for the allegations listed above. LPA met with Nick Moriana, Head of Service who helped facilitate the inspection. Over the course of the investigation, LPA conducted confidential interviews and a file review. Evidence obtained revealed that for the allegation of, Licensee did not keep facility free of rodents and staff permitted minor to sleep on a couch are found to be substantiated. During interviews, 3 of 3 staff stated that the allegations did occur. In response the facility has a pest control company that comes to the facility and are still having trouble with rodents in the facility, which also results in client sleeping on couch still. Therefore, per evidence obtained, the preponderance of evidence has been met. Based on today's inspection the facility is being cited under sections 80087(a)(3) and 87087(b)(4). An exit interview was conducted, and a copy of this report was left. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Karmen Balhotra LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

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

met_with: Nick Moriana


summary: Complaint Investigation - Substantiated - 3 allegations

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Investigation Findings:
13On 03/20/2024 at 12: PM, Licensing Program Analysts (LPA) Jasmine Cardeno and LPA Shikya Belfield made an unannounced visit to initiate a complaint investigation at Palo Verde House to deliver the findings on the listed allegation. LPA Cardeno and LPA Belfield met with Tony Beane, Facility Manager. During the course of the investigation, LPA Cardeno and LPA Belfield toured the facility, conducted confidential interviews, and had documentation including photo evidence of the refrigerator being locked up and not being accessible for the clients in care. Based on confidential interviews and supportive documentation that include but not limited to photographs the preponderance of evidence standard has been met, the allegation, "Staff did not ensure food was accessible to minor in care" is substantiated. Food service regulation 87076(c)(1), is being cited on the attached LIC9099-D. An exit interview was conducted and a copy of this report was given to Tony Beane, Facility Manager, whose signature on this form confirms receipt of these documents. Appeal rights were given to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Jasmine Cardeno LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Tony Beane, Facility Manager


summary: Complaint Investigation - Unsubstantiated - 3 allegations

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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted, although it may have happened, there is not enough evidence to prove that Staff did not pick up minor from school, Staff does not respond to school's phone calls, or that Staff did not seek medical care for minor. Therefore, these allegations are unsubstantiated. There were no violations of Interim Licensing Standards or California Code of Regulations, Title 22, Division Six, cited during this inspection. An exit interview was conducted and a copy this report will be left with facility manager Deby Elkins. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

met_with: Deby Elkins


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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted and supportive evidence to include but not limit, video recording and observation of staff schedule. Although it may have happened, there is not enough evidence to prove that staff threatened youth in care. Therefore, this allegation is unsubstantiated. There were no violations of Interim Licensing Standards or California Code of Regulations, Title 22, Division Six, cited during this inspection. An exit interview was conducted and a copy this report will be left with facility manager Deby Elkins. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90


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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on Confidential interviews conducted, observations of LPA's during inspections on at least two occasions, and obtained documentation to include but not limit Grocery receipts, menus, and photographs. It was confirmed that clients' meals were not always prepared by staff and facility food supply was not sufficient to meet the needs of the clients in care, therefore the allegation "Staff do not ensure minors are fed meals," is found to be SUBSTANTIATED. Facility is cited for violation of Interim licensing standards, section 87076(c)(1) Food Service as described on the following page LIC9099D. An exit interview was conducted a copy of this report along with appeal rights was left with facility manager Deby Elkins. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


summary: Complaint Investigation - Unsubstantiated - 5 allegations

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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted, due to changing with staffing and program structural changes, there are at least two occasions where clients missed their doctor's appointment and/or therapy appointment. Based on confidential interviews conducted and observed supportive documentation to include but not limit; medication administration records and incident reports, clients did not consistently receive medication as prescribed. Based observed supportive documentation, inappropriate comments were made towards clients and the clients were made to feel uncomfortable and reported this information to the staff. The preponderance of the evidence has been met; therefore, these allegations are Substantiated. Facility cited for violation of Interim Licensing Standards sections 87075(d) Health Related Services and 80075(b) Health Related Services as described on the following page LIC9099D. A violation is not being issued for violation of personal rights due to the facility previously being cited and currently working on their plan of correction for this deficiency. An exit interview was conducted a copy of this report along with appeal rights was left with Facility manager Deby Elkins. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90


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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted, clients did not received allowance for at least two weeks. It was also confirmed that staff threatened clients in care regarding their placement and disclosing information regarding client's. Based on confidential interviews conducted, it was confirmed that staff were inappropriate with clients when discussing undergarments. Based on confidential interviews and observed video surveillance, it was confirmed that staff smoke at the facility. The preponderance of evidence has been met; therefore, these allegations are Substantiated. Facility is cited for violation of Interim Licensing Standards, Sections, 87072(c)(16) Personal Rights, 87072(c)(36) Personal Rights, and 87087(c) Buildings and Grounds as described on the following page LIC9099D. An exit interview was conducted a copy of this report along with appeal rights was left with Facility manager Deby Elkins. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted, it was confirmed that staff threatened clients in care with losing their placement. The preponderance of evidence has been met; therefore, this allegation is Substantiated. Facility is cited for violation of Interim Licensing Standards, Section 87072(c)(16) Personal Rights as described on the following page LIC9099D. An exit interview was conducted and a copy of this report along with appeal rights was left with facility manager Deby Elkins. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

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


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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted, and observed supportive evidence to include but not limit, observations by LPA in the facility, photos, and pest control invoice. Minor had a damaged soiled mattress in their room and this mattress was thrown out by another client. There is no clear explanation as to when and where the new mattress for the client came from and the client slept in the living room for short period of time. It was also observed by LPA's during inspections that holes were in the wall for at least one month and there is no knowledge from staff why the repairs have not been done. Based on observations of photographs and invoice from pest control, the facility has mice and the maintenance of keeping the home pest free is not being done. Based on confidential interviews conducted and observations by LPA's Belfield, Cardeno, and Lam during different inspections as well as a review of staff schedules, the facility is not consistently in ratio for the STRTP and utilizes head of service as part of the staffing ratio which is a violation of the regulations. The preponderance of evidence has been met; therefore, these allegations are Substantiated. Facility is cited for violation of Interim Licensing Standards, Sections 80087(a) Buildings and Grounds, 87088(c)(1) Fixtures, Furniture, Equipment, and Supplies, 80076(a)(17) Food Services, 87065(g) Personnel Requirements and 87065. Direct Care Staff/Child Ratios as described on the following page LIC9099D. An exit interview was conducted and a copy of this form along with appeal rights was left with facility manager Deby Elkins. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90


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Investigation Findings:
13On 5/3/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with facility manager Deby Elkins who assisted with the inspection. Based on confidential interviews conducted, it was confirmed that staff ( S1 see LIC811 dated 5/3/2024) came to work under the influence during the overnight shift. It was also confirmed that the actions of the staff and the verbiage used by staff make clients in care feel uncomfortable. Therefore, these allegations are Substantiated. Facility cited for violations of Interim Licensing Standards, section 87001(c)(10) "Conduct inimical as described on the following page LIC9099D. A civil penalty is being assessed. An exit interview was conducted and a copy of this report along with appeal rights was left with facility manager Deby Elkins. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: PALO VERDE HOUSEFACILITY NUMBER: 075650097

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


summary: Complaint Investigation - Unsubstantiated

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Investigation Findings:
13On 07/26/24 at, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced complaint inspection at the above facility. The purpose of this inspection is to inform the facility representative of the findings for the allegations above. LPA met with the Facility Manager and Facility Administrator who assisted with the inspection. Based on confidential interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations above occurred. Therefore, these allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was left and emailed to the Facility Manger and Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio 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