summary: Facility Evaluation

raw_content:
Narrative:
On 04/22/2026 at 9: AM Licensing Program Analyst (LPA) Cheri Wilkerson made an unannounced visit to above facility for the purpose of conducting a Random/Annual licensing Inspection. LPA met with the Licensee who granted access into the home, and who provided a tour. This facility is Licensed to provide care and supervision for three Developmentally Disabled children ages 2-17 years of age and are Ambulatory. Currently residing in the home are the Licensee and 2 foster children in placement. There are no bodies of water on the premises. The Licensee confirmed that there are no firearms or dangerous weapons in the home. This is 1 story split level, five bedrooms and two bathrooms; two car garage, located in a residential neighborhood. Living room; Dining room, Kitchen, and a Den. The home has central heat and air throughout. Outdoor Area: The outdoor perimeter, front yard, side yard and backyard were inspected. There were no hazards materials to be found. LPA observed all windows, screens and blinds from the inside and outside of the SFH were observed to be in good condition. There are retractable bars on the back windows of bedroom #2 and #3. The passageways and porches are unobstructed. There is a two-car garage with a locked pad utilizing extra furniture and supplies. There is one home vehicle parked outside inspected to be in good operating condition (The vehicle car was checked for tires, headlights, taillights, turn signals, horn and windshield wipers). Make and Model ( Honda Odyssey Van). LPA reviewed the proof of Insurance (AAA 07-24-2026); Car Registration (Expiration 09/18/2026) and current Driver's License to expire in March 23, 2031. There is a non-operable vehicle ( Volkswagen) locked and covered in the back yard. Page 1 0f 4. Bedroom # Is currently unoccupied; located on right side entrance of the living room with key lock entry. It is equipped with one (1) twin sized bed, clean linen, comfortable mattress, clean linens, blankets, and pillows, as needed, all in good repair, adequate drawers and a walk-in closet. Bedroom # Is currently unoccupied; located on right side entrance of the living room with key lock entry. It is equipped with one (1) twin sized bed, clean linen, comfortable mattress, clean linens, blankets, and pillows, as needed, all in good repair, adequate drawers and a walk-in closet. Bedroom # Is occupied by child #1 with special health care needs. It is equipped with one twin size bed, comfortable mattress, clean linen, blankets, and pillows, adequate drawers and a walk-in closet. Bedroom # Is occupied by child #2 with special health care needs. It is equipped with one twin sized bed, equipped, comfortable mattress, clean linen, blankets, and pillows, adequate drawers and a walk-in closet. Bedroom # Is currently occupied the Licensee. The entrance is through the den. It is equipped with one twin sized bed, comfortable mattress, clean linen, blankets, and pillows, adequate drawers and a walk-in closet. There are two Bathrooms inspected and found to be clean. LPA tested the water temperature, bathroom sinks and ensured that all toilets flushed. The water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is located between Bedroom #2 and #3. It is equipped with a one sink, bathtub, shower, and one toilet. There is adequate lighting. Developmentally appropriate toiletries and personal hygiene products, for the children are in the hallway above linen closet. Bathroom #2 is located across from Bedroom #4. There is one sink, tub, and one toilet. There is adequate lighting, blinds and a window with a retractable bar; observed to be in good condition. Page 2 of Linen Closet is in the hallway adjacent to Bedroom #2 and #3. LPA observed to have ample clean linen. Dining room/ Small Office Space There is ample lighting over the large dining table that seats 4 people. This same area has a small computer desk, small t Desk top printer, office supplies, shelves and drawers. There is a fully stocked First aid kit. LIC-809-C Page 2 of DEN There is a 4-Step stairway with a rail that leads to the Den. There is locked bar door that leads the outside side entrance of the house. The Den is equipped with furniture, one television, toys, book shelf, and a locked file cabinet for personal files, and children's records,. Kitchen/Dining room Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with four burners a double door refrigerator and a side freezer; microwave and a toaster. There is door that leads to the side/front house. LPA observed coverage trash cans in the kitchen, and bathrooms. LPA observed ample fresh perishable and nonperishable food in the home in a quantity to meet the needs of the next three meals and snack between meals. LPA observed sharp knives inaccessible in separate box in the top kitchen cabinet. The food preparation area where kitchen equipment has pots, pans and utensils. The Fire Extinguisher is in the kitchen; fully charged. All posting requirements were met (Personal rights and the food menu are posted on the refrigerator) Medication is locked in the upper kitchen cabinet and not accessible to the children. The Licensee is responsible for administering medication. Prescribed medications: medication logs, files and locked key in the kitchen. Medication is also stored in the refrigerator in a locked box. LPA reviewed the Medication Administration Record (MAR) for both children recorded for six months. LPA observed utility shut-off valves for gas and water located on right side of house. The Hot Water Heater is enclosed inside the house in the hallway adjacent to the laundry room. Page 3 of 4. Laundry Room: The Washer and Dryer (White)unit is also located inside a room near bathroom #2. The Licensee selected to do the laundry for the children. The Laundry detergent, cleaning supplies solutions, disinfectants, pesticides and other similar toxic chemicals stored in a locked cabinet. LPA observed combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is fully furnished with one ceiling fan, entertainment center, a music keyboard, China cabinet, bookshelf, desk and storage bins. Clients will be accorded dignity in personal relationships with all adults authorized to be in contact with clients. The licensee provides the opportunity for the children to participate in extracurricular activities for children with special needs. LIC-809-C Page 3 of Client Records: LPA reviewed one client file for children with Special Needs. Staff Records: Currently there are no staff employed other than the Licensee. LPA reviewed Licensee's various training; Certified of Completion (CEU) Continuing Education Units by Colibri Healthcare, CPR, and Crisis Consultant Group (Escape and Evasion Techniques). LPA obtained the Facility Profile and Personnel Report and confirmed that the Licensee have required criminal record clearances. DOJ, FBI and Child Abuse Response, which meet qualification. Client Interviews: Clients were unable to be interview due to Developmentally Disabilities. There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report will be emailed to Licensee. LIC-809-C Page 4 of 4

met_with: Lavona Wells, Licensee


state: CA

facility_name: WHERE THERE'S A WILL

summary: Facility Evaluation

raw_content:
Narrative:
On August 21, 2025, at 9:30AM, Licensing Program Analyst (LPA) Rachel Vanegas met with Where There's A Will Small Family Home (SFH) Applicant, Willie Warren, at the Riverside Children's Residential Regional Office for the purpose of conducting a Component II meeting. LPA discussed corrections and revisions needed for the Program Statement and supporting documents. The following is a summary of the corrections and revisions discussed and requested. These revisions are due by close of business on September 5, 2025. Guardian: The applicant is not currently associated or eligible with the Small Family Home #366000026. A1. Application (LIC 200) Please provide an original document for the updated application reflecting changes submitted on 07/03/2025. A2. Applicant Information (LIC 215) Please provide training certificates to reflect applicable training requirements for qualifications and experience verification. A4. Affidavit Regarding Client Cash Resources (LIC 400) Please provide original documents for the revisions submitted on 07/03/2025. Please review and revise the amount that you will safeguard to align with the amount of bond you have selected. **** A9. Budget Information (LIC 420) Please review and include the names and ages of the person's income you have included in this document. Please also identify sources of income. A10. Personnel Report (LIC 500) Please remove "administrator" and "back-up administrator" as job titles identified on this document. A11. Personnel Record (LIC 501) Please provide training certificates to reflect applicable training requirements for qualifications and experience verification. Please provide an LIC 501 for additional staff identified on LIC 500. A12. Health Screening Report (LIC 503) Please provide the original document for revisions submitted on 07/03/25. Please review and revise Position Title to state "Licensee". Please provide an LIC 503 for additional staff identified on LIC 500. A13. Criminal Record Statement (LIC 508D) Please complete this document for Where There's A Will SFH. A14. Emergency Disaster Plan (LIC 610C) Section I: Revise Administrator job titles to state Licensee. Section II: Include names of identified emergency service numbers provided. Section IV: Provide signed authorization letters for the use of relocation sites from the agency or business owners, including their name and job title. A15. Facility Sketch (LIC 999) Identify camera locations on the facility grounds All client bedrooms must be identified on the sketch of the facility Indicate exit routes by number as shown on the LIC 610C Emergency Disaster Plan A16. Fire Inspection LPA will follow up regarding fire clearance request. Per applicant, this has not been completed. **** B7. Facility Program Description Please review and revise Table of Contents for accuracy Please clarify client sources (placement agencies) intended for your program Please review and revise all references to "Administrator/Owner" to "Licensee" Please remove references to Inland Regional Center as per discussion, this does not apply. Please identify all acronyms and abbreviations before use (ex. DSP, CCL, etc.) Goals Please ensure that references to communication and connections with family, etc. is in alignment with court orders. (Pg. 4) Please ensure that you identify a consistent reference to clients as "Consumers" or "Children", etc. (Pg. 4) Please provide more information regarding "base" staff to client ratio that your program will provide. (Pg. 5) Please provide a daily schedule of activities to be provided by the facility. This should state who plans, conducts and assists clients in participating in these activities. Please provide a one month schedule of planned social, educational and recreational activities. This should state who plans, conducts, and assists clients in participating in these activities. Client Population To Be Served Please identify placement source (Pg. 6) Please review and revise reference to posting confidential information outside of client bedrooms (pg. 6) Please provide clarification regarding reference to "medication dispensing" (Pg. 6) Medication Please specify adequate and appropriate medication storage (Pg. 7) Medical Assessment/TB Test prior to or within 30 days of acceptance Please describe where first aid supplies and a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency will be stored. Please describe how staff that are responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. **** Please describe how psychotropic medication shall only be used in accordance with the written directions of the physician prescribing the medication and in accordance with authorization requirements specified in Sections 369.5(a)(1) and 739.5(a)(1) of the Welfare and Institutions Code and Section 83070(b)(11). Please describe how the facility will obtain a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication, as defined in Section 84001(p)(4). Please include that there can be temporary administration of psychotropic medication authorized on the JV220(A) Physician's Statement while the JV223 is pending Please describe or provide the consent forms, completed by the child's authorized representative(s), to permit the facility to authorize medical care. Please provide a statement that medication errors will need to be reported and documented to Community Care Licensing (CCL), per reporting requirements timeframes. Please provide a statement that any medication refusal by a client is considered a "Special Incident" and a report will be sent to CCL. Please revise and revise reference to Title 17 & Title Regulations (Pg. 8) Please revise and provide more information and clarity to the medication destruction policy to state how the medication will be transported and documented (by who, when, etc.) to be destroyed by the issuing pharmacy (Pg. 12) Please provide timelines for medication refill request procedure (Pg. 12) Please specify the frequency of medication storage audits that will be conducted by the Licensee (Pg. 14) Transportation Please describe how the motor vehicles used to transport clients shall be maintained in safe operating condition. Please include a statement stating that the licensee and their staff are prohibited from smoking a tobacco product or permitting any person from smoking a tobacco product in a motor vehicle that is regularly used to transport children, regardless of when the children are present. This prohibition applies when the motor vehicle is moving or at rest. Please include statement that the licensee shall provide transportation for a child in a timely manner to and from the following: **** (1) Health-related services. (2) School. (3) Extracurricular, enrichment, cultural, and social activities, in accordance with the reasonable and prudent parent standard specified in Section 83067. Please describe how the facility shall ensure that the transportation provided safeguards the health and safety of a child and shall not violate the personal rights of a child as required by Section 83072. No Corporal Punishment Please review and revise any reference to physical restraint, as this is not allowed, etc. (Pg. 27 and Page 28) Needs and Services Plan Please review and revise this section to clearly identify the Licensee's responsibility for creating a Needs and Services Plan for a client within 30 days of placement. (Pg. 29) Visiting Please review and clarify where identified visits will occur (Pg. 31) Procedures for Reporting Incidents Please review and revise this section to provide a procedure that includes timeframes including how to submit a grievance/complaint, who responds, the timeframe, how the outcome is documented, where the procedure is documented. Please include complaint hotline phone number/contact information and CCL information as well (Pg. 34) Notes Please provide information and clarify the use of Daily Supervisory Notes or remove it (Pg. 35) Admission Agreement Please provide the Admission Agreement on a separate and stand-alone page/document (Pg. 38) It currently is started on a page that includes Community Resources, etc. **** Please include space for required signatures on the Admission Agreement (Pg. 40) You may utilize the LIC 604 as a reference or guide to ensure that all of the required information is present on your Admission Agreement. Please identify the following: - Persons accepted for care, including age range and compatibility determination process, when necessary. - Criteria for assessing appropriateness of placement given an individual client's needs (i.e., interviews, procedures for obtaining and developing the necessary paperwork, etc.) - Needs and services plan. - Provide a statement that clients/residents will be informed of their rights and that client's/resident's rights will not be violated). - Describe the pre-admission appraisal plan in this section. - Describe how the facility will obtain emergency information. - Describe the sign-in and sign-out procedures. - Describe the physical examination requirements/immunization requirements in this section. Including Tuberculosis screening. Rules of Discipline/Personal Rights: Please include reference to grounds for dismissal/relocation/removal from placement. Please describe how the child and authorized representative will sign the personal rights form at intake and each time a new right has been added. (Lic 613b (06/22)). Please include how a copy of the discipline policy will be reviewed and provided to the child and authorized representative and will be signed by both parties as well. Sample Menu: Please include a sample menu that will reflect: Planned meals and snacks for one week (minimum), foods used should be from the four basic food groups. Portion sizes. Times meals served. Addendum: Please review and revise/identify where cameras are located and include information to ensure compliance with Children's Residential Program Provider Information Notice 24-09 (pg. 43) LPA Vanegas conducted an exit interview and a copy of this report along with the signed LIC 281C, Care Tools Pre-licensing form, and Children's Residential Program Provider Information Notice 24-09 were reviewed and provided to the applicant, Willie Warren.

report_type: Facility Evaluation

met_with: Applicant - Willie Warren


summary: Facility Evaluation

raw_content:
Narrative:
On November 26, 2025 at 09: AM, Licensing Program Analyst's (LPAs) Rachel Vanegas and Valerie Wilson arrived at Where There's A Will Small Family Home (SFH) to conduct a pre-licensing inspection. LPAs met with Applicant - Willie Warren who led a tour of the home. The home was toured both inside and out with the applicant. Currently there are no clients in placement. The home is a one story building with four bedrooms and two bathrooms which are set up as follows: Bedroom #1 (Master) has one bed sleeps the Applicant Bedroom #2 (Clients) has two single beds and will sleep two clients Bedroom #3 (Applicant's Adult Child) has one single bed and sleeps the applicant's adult child Room #4 (Flex Room) is used as a recreation room The home also consists of a great room/living room, kitchen, dining area, two bathrooms, a locked laundry room, a two car garage, and the backyard. The client's bedroom is arranged so that no more than two client's will be in the room. No room commonly used for other purposes is used as a bedroom and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. There were combo smoke/carbon monoxide detectors in every bedroom and hallway. The combo detectors were checked and in properly functioning order. The home's central air conditioning module was located in the back yard. The home's tankless water heater was located in the garage and was set at 116. Degrees Fahrenheit. The home appliances were in working order at the time of this inspection. *Continued on the next page* The client and staff files will be located in a locked storage closet in the hallway. There was adequate food storage space. LPAs observed a two day supply of perishable and a seven day supply of non-perishable food. A trash can for storage of solid waste had a tight-fitting lid and was present in the kitchen. The sharp knives are located in a locked kitchen cabinet under the sink, inaccessible to clients. The medications will be located in a locked storage cabinet in the hallway near the laundry room. The hot water in the kitchen was measured and registered at 110.6 degrees Fahrenheit. The home's First Aid kit was accessible and is located in the kitchen and contained all required supplies. There were two fire extinguishers present in the home. One fire extinguisher is located in the kitchen under the sink and one is located in the garage. Both fire extinguishers were observed to be properly charged and inspected by the fire department. There are two firearms in the home in a secured safe located in the master bedroom, which is locked and inaccessible to clients in care. The ammunition is stored in a separate safe in the applicant's locked master bedroom closet, separate from the firearm. There is no pool or accessible body of water at the home at the time of this inspection. The backyard where clients will have access to play is fenced. The home has three security cameras located on the outside perimeter of the home (door bell and two views of the backyard, outdoor and indoor cameras do not record audio). There is one motion sensor in the living room and chimes on all doors and windows. There will be two additional cameras installed inside of the home (one in the hallway/entryway and one in the living room/dining room). The following corrections need to be made: Final revisions to program statement including Video Surveillance Policy and Psychotropic Medication Administration. Component III was completed during this visit. An exit interview was conducted and a copy of this report and appeal rights were reviewed and provided to the applicant, Willie Warren. Application will be forwarded to the Licensing Program Manager for Licensing upon receipt and confirmation of corrections made to the Program Statement and final fire clearance approval being received.

visit_type: Prelicensing


facility_name: WHITE SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 06/29/21 at 11:30 am, Licensing Program Analyst (LPA), Zena Phillips and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to the White Small Family Home to conduct a required/random inspection. LPA met with Edmond White who granted access to the home and a tour of the home was conducted together. The facility is licensed to care for four (4) Developmentally Disabled children ages 3-17 years, Ambulatory only. They only accept Regional Center clients. The census today is two (2). Currently residing in the home are Licensees and children. The home is operating within the capacity and limitations of license.Children have individual beds, comfortable mattresses, clean linens, blankets, and pillows, that are in good condition.The home is clean, safe and sanitary, and in good repair. Outdoor activity space is free of obstructions and hazards. There are no firearms in residence. The home is set up as follows: This is a two story home with five (5) bedrooms, four (4) bathrooms, family room, living room, dining area, kitchen, and dining area. The home is clean, safe, sanitary, and in good repair. Adequate supervision is provided for children in care. Bedroom # 1- Occupied by adopted child There is one full size bed, bathroom, adequate drawer space, restroom, closet and lighting. Bedroom # 2 -Occupied by C1 and C2. There are two full size beds, bathroom, adequate drawer space, closet and lighting. Comfortable mattresses, clean lines, blankets, and pillows that are in good repair. Bedroom # 3- Is vacant. There are two full size beds and adequate drawer space, closet and lighting. comfortable mattresses, clean lines, blankets, and pillows that are in good repair. Bedroom # 4- Occupied by Licensees There is a queen size bed, restroom, office space, adequate drawer space, closet and lighting. Bedroom # 5- guest room. There is a full size, adequate drawer space, closer and lightning. Bathrooms: There are four (4) bathrooms. Toilets, sinks, tub/showers are clean and in operating condition. Water temperature measured within a safe range. Living Room: There is a television, furniture is in good repair. Fire place available that is locked and safe. Dining Area: One table with eight chairs. Kitchen: There is a stove/oven with (4) burners all working currently. There is a microwave and refrigerator/freezer. There is a table with six chairs. They have adequate perishable and nonperishable food available. All knives, trash, disinfectant and cleaning solutions are inaccessible to children. They are locked in top cabinet in the kitchen. Licensee ensures three nutritious meals, snacks, and special diets. Food supply is ample in the home. Laundry Room: A washer and dryer available. Backyard: Outdoor activity space is free of obstructions. There are no bodies of water on the premises. Two big dogs on the premises, both have valid license and up to date shot records. There is a fire pit and basketball court Licensee provides services identified in child's needs and services and individualized health care plans for children with special health care needs. Licensee provides for direct supervision of clients participating in or present at potentially dangerous activities or areas in the facility. Facility personnel are instructed to report observations or evidence of violations of the child's personal rights. Children can contact the licensing agency or the Foster Care Ombudsperson in confidence without threats or punishment or retaliation for making complaints. Children have the right to attend school and participate in extracurricular, cultural, and personal enrichment activities consistent with the child's age and developmental level. Caregivers safeguards children's resources, personal property, and valuables. Caregiver has written authorization to obtain medical and dental care. Personal rights forms in children files. Caregivers and other adults residing in the home have Child Abuse Index Checks. Facility personnel files document that staff meet qualification requirements Emergency Disaster and Mass Casualty is current and available for review. Emergency Disaster and Mass Casualty Plan: designations of administrative authority and staff assignments are current. Home maintains appropriate Fire Clearance. There are no deficiencies cited and exit interview conducted.

visit_type: Annual

met_with: Edmond White


summary: Facility Evaluation

raw_content:
Narrative:
On 05/12/22 at 8:30 am, Licensing Program Analyst (LPA), Zena Phillips and Licensing Program Analyst (LPA) Kuliema Calloway made an unannounced visit to the White Small Family Home to conduct a required/random inspection. LPA's met with Antonia White who granted access to the home and a tour of the home was conducted together. The facility is licensed to care for four (4) Developmentally Disabled children ages 3-17 years, Ambulatory only. The facility currently has two clients age 20 years old. They only accept Regional Center clients. The census today is two (2). Currently residing in the home are Licensees and children. The home is operating within the capacity and limitations of license. Children have individual beds, comfortable mattresses, clean linens, blankets, and pillows, that are in good condition. The home is clean, safe and sanitary, and in good repair. Outdoor activity space is free of obstructions and hazards. There are no firearms in residence. The home is set up as follows: This is a two story home with five (5) bedrooms, four (4) bathrooms, family room, living room, dining area, kitchen, and dining area. The home is clean, safe, sanitary, and in good repair. Adequate supervision is provided for children in care. Bedroom # 1- Occupied by adopted child There is one full size bed, bathroom, adequate drawer space, restroom, closet and lighting. Bedroom # 2 -Occupied by C1 and C2. There are two full size beds, bathroom, adequate drawer space, closet and lighting. Comfortable mattresses, clean linens, blankets, and pillows that are in good repair. cont on 809 c Bedroom # 3- Is vacant. There are two full size beds and adequate drawer space, closet and lighting. comfortable mattresses, clean lines, blankets, and pillows that are in good repair. Bedroom # 4- Occupied by Licensees There is a queen size bed, restroom, office space, adequate drawer space, closet and lighting. Bedroom # 5- guest room. There is a full size, adequate drawer space, closer and lightning. Bathrooms: There are four (4) bathrooms. Toilets, sinks, tub/showers are clean and in operating condition. Water temperature measured within a safe range. Living Room: There is a television, furniture is in good repair. Fire place available that is locked and safe. Dining Area: One table with eight chairs. Kitchen: There is a stove/oven with (4) burners all working currently. There is a microwave and refrigerator/freezer. There is a table with six chairs. They have adequate perishable and nonperishable food available. All knives, trash, disinfectant and cleaning solutions are inaccessible to children. They are locked in top cabinet in the kitchen. Licensee ensures three nutritious meals, snacks, and special diets. Food supply is ample in the home. Laundry Room: A washer and dryer available. Backyard: Outdoor activity space is free of obstructions. There are no bodies of water on the premises. One big dog on the premises, with valid license and up to date shot records. There is a fire pit and basketball court. Licensee provides services identified in child's needs and services and individualized health care plans for children with special health care needs. Licensee provides for direct supervision of clients participating in or present at potentially dangerous activities or areas in the facility. comt on 809c Facility personnel are instructed to report observations or evidence of violations of the child's personal rights. Children can contact the licensing agency or the Foster Care Ombudsperson in confidence without threats or punishment or retaliation for making complaints. Children have the right to attend school and participate in extracurricular, cultural, and personal enrichment activities consistent with the child's age and developmental level. Caregivers safeguards children's resources, personal property, and valuables. Caregiver has written authorization to obtain medical and dental care. Personal rights forms in children files. Caregivers and other adults residing in the home have Child Abuse Index Checks. Facility personnel files document that staff meet qualification requirements Emergency Disaster and Mass Casualty is current and available for review. Emergency Disaster and Mass Casualty Plan: designations of administrative authority and staff assignments are current. Home maintains appropriate Fire Clearance. There are no deficiencies cited and exit interview conducted and copy of report will be emailed to Licensee

met_with: Antonia White/ Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 06/21/2023 at 9: AM, Licensing Program Analyst (LPA), Zena Phillips made an unannounced visit to the White Small Family Home to conduct a Required Annual Inspection. LPA met with Antonia White who granted access to the home and a tour of the entire home was conducted together. The facility is licensed to care for four (4) Developmentally Disabled children ages 3-17 years, Ambulatory only. The facility currently has two (2) clients age 21 years old. They only accept Regional Center clients. The census today is 1 (one). Currently residing in the home are Licensees and children. The home is operating within the capacity and limitations of license. Children have individual beds, comfortable mattresses, clean linens, blankets, and pillows, that are in good condition. Outdoor activity space is free of obstructions and hazards. There are no firearms in residence. The home is set up as follows: This is a two story home with five (5) bedrooms, four (4) bathrooms, family room, living room, dining area, kitchen, and breakfast dining area. Adequate supervision is provided for children in care. Bedroom # 1- Occupied by adopted child There is one full size bed, bathroom, adequate drawer space, restroom, closet and lighting. Bedroom # 2 -Occupied by C1 and C2. There are two full size beds, bathroom, adequate drawer space, closet and lighting. Comfortable mattresses, clean linens, blankets, and pillows that are in good repair. cont on 809 c Bedroom # 3- Is vacant. There are two full size beds and adequate drawer space, closet and lighting. comfortable mattresses, clean lines, blankets, and pillows that are in good repair. Bedroom # 4- Occupied by Licensees There is a queen size bed, restroom, office space, adequate drawer space, closet and lighting. Bedroom # 5- guest room. There is a full size, adequate drawer space, closet and lighting. Bathrooms: There are four (4) bathrooms. Toilets, sinks, tub/showers are clean and in operating condition. The hot water measured at 113.5 degrees and is within the acceptable temperature range of 105 and 120 degrees. Living Room: There is a television, furniture is in good repair. Fire place available that is locked and safe. Dining Area: One table with eight chairs. Kitchen: There is a stove/oven with (4) burners all igniting when turned on. There is a microwave and refrigerator/freezer. There is a table with six chairs. They have adequate perishable and nonperishable food available. All knives, trash, disinfectant and cleaning solutions are inaccessible to children. They are locked in top cabinet in the kitchen. Licensee ensures three nutritious meals, snacks, and special diets. Food supply is ample in the home. Laundry Room: A washer and dryer available. Backyard: Outdoor activity space is free of obstructions. There are no bodies of water on the premises. One big friendly and well mannered dog on the premises, with valid license and up to date shot records. There is a fire pit and basketball court. Licensee provides services identified in child's needs and services and individualized health care plans for children with special health care needs. Licensee provides for direct supervision of clients participating in or present at potentially dangerous activities or areas in the facility. Facility personnel are instructed to report observations or evidence of violations of the child's personal rights. Children can contact the licensing agency or the Foster Care Ombudsperson in confidence without threats or punishment or retaliation for making complaints. cont on 809c Children have the right to attend school and participate in extracurricular, cultural, and personal enrichment activities consistent with the child's age and developmental level. Caregivers safeguards children's resources, personal property, and valuables. During the inspection LPA Phillips conducted confidential interviews, staff and client file review. LPA observed files to be in compliance. Staff files included, criminal record clearance with signature, Trauma Informed Care Training Certificates. Client files included authorization for medical and dental care, along with personal rights. Caregiver has written authorization to obtain medical and dental care. Personal rights forms in children files. Caregivers and other adults residing in the home have Child Abuse Index Checks. Facility personnel files document that staff meet qualification requirements Emergency Disaster and Mass Casualty is current and available for review. Emergency Disaster and Mass Casualty Plan: designations of administrative authority and staff assignments are current. Home maintains appropriate Fire Clearance. The home is clean, safe and sanitary, and in good repair. There are no deficiencies cited and exit interview conducted and copy of report was left with Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 06/20/2024 at 10: AM Licensing Program Analysts (LPA), Zena Phillips made an unannounced visit to the White Small Family Home to conduct a Required Annual Inspection. LPA met with Edmond White who granted access to the home and a tour of the entire home was conducted together. The facility is licensed to care for four (4) Developmentally Disabled children ages 3-17 years, Ambulatory only. The facility currently has one (1) clients age 22 years old. They only accept Regional Center clients. The census today is one (1). Currently residing in the home are Licensees and children. The home is operating within the capacity and limitations of license. Children have individual beds, comfortable mattresses, clean linens, blankets, and pillows, that are in good condition. Outdoor activity space is free of obstructions and hazards. There are no firearms in residence. The home is set up as follows: This is a two story home with five (5) bedrooms, four (4) bathrooms, family room, living room, dining area, kitchen, and breakfast dining area. Adequate supervision is provided for children in care. Bedroom # 1- Occupied by adopted child There is one full size bed, bathroom, adequate drawer space, restroom, closet and lighting. Bedroom # 2 -Occupied by C1. There are two full size beds, bathroom, adequate drawer space, closet and lighting. Comfortable mattresses, clean linens, blankets, and pillows that are in good repair. Bedroom # 3- Is vacant. There are two full size beds and adequate drawer space, closet and lighting. comfortable mattresses, clean lines, blankets, and pillows that are in good repair. cont 809c Bedroom # 4- Occupied by Licensees There is a queen size bed, restroom, office space, adequate drawer space, closet and lighting. Bedroom # 5- guest room. There is a full size, adequate drawer space, closet and lighting. Bathrooms: There are four (4) bathrooms. Toilets, sinks, tub/showers are clean and in operating condition. The hot water measured at 113.5 degrees and is within the acceptable temperature range of 105 and 120 degrees. Living Room: There is a television, furniture is in good repair. Fire place available that is locked and safe. Dining Area: One table with eight chairs. Kitchen: There is a stove/oven with (4) burners all igniting when turned on. There is a microwave and refrigerator/freezer. There is a table with six chairs. They have adequate perishable and nonperishable food available. All knives, trash, disinfectant and cleaning solutions are inaccessible to children. They are locked in top cabinet in the kitchen. Licensee ensures three nutritious meals, snacks, and special diets. Food supply is ample in the home. Laundry Room: A washer and dryer available. Backyard: Outdoor activity space is free of obstructions. There are no bodies of water on the premises. One big friendly and well mannered dog on the premises, with valid license and up to date shot records. There is a fire pit and basketball court. Licensee provides services identified in child's needs and services and individualized health care plans for children with special health care needs. Licensee provides for direct supervision of clients participating in or present at potentially dangerous activities or areas in the facility. Facility personnel are instructed to report observations or evidence of violations of the child's personal rights. Children can contact the licensing agency or the Foster Care Ombudsperson in confidence without threats or punishment or retaliation for making complaints. Children have the right to attend school and participate in extracurricular, cultural, and personal enrichment activities consistent with the child's age and developmental level. Caregivers safeguards children's resources, personal property, and valuables. cont on 809c During the inspection LPA Phillips conducted two (2) confidential interviews, two (2) staff and one (1) client file review. LPA observed files to be in compliance. Staff files included, criminal record clearance with signature, Trauma Informed Care Training Certificates. Client files included authorization for medical and dental care, along with personal rights. Caregiver has written authorization to obtain medical and dental care. Personal rights forms in client files. Caregivers and other adults residing in the home have Child Abuse Index Checks. Facility personnel files document that staff meet qualification requirements Emergency Disaster and Mass Casualty is current and available for review. Emergency Disaster and Mass Casualty Plan: designations of administrative authority and staff assignments are current. Home maintains appropriate Fire Clearance. The home is clean, safe and sanitary, and in good repair. There are no deficiencies cited and exit interview conducted and copy of report will be provided Licensee.

met_with: Edmond & Antonia White/Licensee


facility_name: WIGGINS FAMILY HOME

summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) T. Davis conducted a Component II at the Monterey Park Children's Residential Regional Office on September 13, 2024 at 2:00pm with the Wiggins Family Home SFH. LPA met with the applicant, Kendra Wiggins, and discussed the following: 1. Staff Associations 2. Small Family Home Program Statement revisions 3. Emergency Disaster Plan 4. Admission Policies 5. Application 6. Surety Bond 7. Menu 8. Placement Criteria/Placement Agencies 9. Criminal Record Statement 10. Incident Reporting LPA asked questions regarding the applicant's Program Statement to assess their understanding of the regulations in place for a Small Family Home. LPA advised the applicant that all revisions/corrections need to be submitted directly to him for further review. The Pre-Licensing inspection will take place on Thursday, September 19, 2024. LPA discussed the upcoming Pre-Licensing inspection in general and what it involves. LPA advised the applicant that their program statement will also be reviewed by his manager, LPM Yan Yeung. Exit interview done

met_with: Kendra Wiggins


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) T. Davis went to the Wiggins Family Home on September 19, 2024 at 11:30am for the purposes of an announced Pre-licensing inspection. The Department has received application materials from the applicant to become licensed at the site as a Small Family Home licensee. LPA met with the applicant, Kendra Wiggins, and together they toured the home. The home is located in a residential neighborhood and consists of three bedrooms and two bathrooms. Bedroom #1 has two twin beds, two dressers, and closet space. The bedroom is vacant. Bedroom #2 has one queen bed, dresser, and closet space. The bedroom is occupied by the applicant. Bedroom #3 has one queen bed, dresser, and closet space. The bedroom is occupied by the applicant's son Sharp knives, chemicals, and cleaning supplies are kept locked in areas inaccessible to children. LPA observed a fully stocked linen closet in the hallway. The living room and dining room areas were observed to be tidy and had sufficient seating. The front yard is enclosed entirely with a gate. The gate is accessible to enter and is not obstructed or bounded by any entrance/exit restrictions. LPA observed two bathrooms to be in good repair and working order. Overall, the facility appeared clean, safe, and sanitary. LPA observed two fully charged fire extinguisher mounted on the wall in the kitchen and hallway areas. The outdoor areas were observed to be free of debris and hazards. There is one camera each in the backyard, front yard, and on the side of the home. The cameras are not pointed at or towards the home. There are no cameras inside the home. LPA held discussions with the Applicant about the cameras. LPA observed the kitchen area to be clean and the refrigerator was fully stocked with ample food supply. LPA observed adequate perishable and nonperishable food items in the cabinets and in the pantry. LPA also observed a complete food menu posted on the refrigerator in the kitchen. The applicant has two small dogs on the premises. The dogs are allowed to roam and play in the backyard, but will not do so if children are outside. The dogs do not stay in the home as they are kept in the garage. The garage is kept locked and has a sign posted that says, "Authorized Personnel Only." The applicant showed LPA copies of the shot records for the two dogs as well as the dog licenses. One license had an expiration date of August 17, 2025 and the other one had an expiration date of September 03, 2025. The applicant stated that there weren't any firearms or other weapons on the premises. There is adequate space for indoor and outdoor activities. LPA observed Emergency information and a facility sketch posted on the wall in the hallway. LPA observed a fully stocked First Aid Kit with an ample amount of bandages and band-aids. The First Aid Kit also contained a thermometer, scissors, tweezers, etc. LPA also observed a fully stocked pantry in the hallway and a fully stocked linen closet in the hallway as well. The Applicant has an adequate laundry area with both a washer and a dryer, respectively. The Applicant stated that there were no swimming pools or other bodies of water on the premises. LPA found no Title 22 deficiencies on this date. Exit interview conducted LPA Davis discussed cooler weather conditions and precautions with the applicant and provided the applicant with the Department's website address (www.ccld.ca.gov). LPA advised Applicant of remaining the steps to become a licensed Small Family Home provider. Exit interview conducted.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) T. Davis went to the Wiggins Family Home on July 24, 2025 at 12:10pm for the purposes of a Post Licensing inspection. LPA met with the licensee and together they toured the home. The facility is a single story home located in a residential neighborhood and has three bedrooms, two bathrooms, kitchen, living room, and a garage. Currently, there is one placement in the home. Bedroom #1 has one queen bed, dresser, and closet space. The bedroom is occupied by the licensee. Bedroom #2 has one queen bed, dresser, and closet space. The bedroom is occupied by the licensee's son. Bedroom #3 has two beds, two dressers, and closet space. The bedroom is occupied by child #1. The smoke alarms were operable in each bedroom. There is adequate seating capacity in the living room and dining area. LPA observed two bathrooms in good repair and working order. The kitchen was observed to be sanitary and has adequate food supply in the refrigerator. Sharp knives, chemicals, and cleaning supplies are kept locked in areas inaccessible to children. LPA observed a fully stocked linen closet in the hallway. The front yard is enclosed entirely with a gate. The gate is accessible to enter and is not obstructed or bounded by any entrance/exit restrictions. Overall, the facility appeared clean, safe, and sanitary. LPA observed fully charged fire extinguishers at the facility. There are no pools or other bodies of water on the premises. The outdoor areas were observed to be free of debris and hazards. There are two cameras in the backyard, one camera on the side of the home, and one camera in the driveway. The cameras are not pointed at or towards the home. There are no cameras inside the home. LPA observed adequate perishable and nonperishable food items in the cabinets and in the pantry. Licensee has two small dogs on the premises. LPA observed copies of the dog licenses for both dogs. LPA also observed shot records for the two dogs as well. Licensee stated that there weren't any firearms or other weapons on the premises. LPA observed a fully stocked First Aid Kit. There is adequate space for indoor and outdoor activities. The last fire drill occurred on April 12, 2025 at 1:30pm. LPA reviewed the file of child #1 and found the reviewed file to be in order. LPA spoke with child #1 during the inspection. Child #1 appeared neat and well groomed. LPA found no Title 22/ILS deficiencies on this date. Exit interview conducted LPA Davis discussed warm weather conditions and precautions with the licensee and provided the licensee with the Department's website address (www.ccld.ca.gov). Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to the Wiggins Family Home on January 15, 2026 at 11:42am for the purposes of an unannounced Required Annual inspection. LPA met with the licensee, Kendra Wiggins, and together they toured the home. The facility is a single story home located in a residential neighborhood and has three bedrooms, two bathrooms, kitchen, living room, and a garage. Currently, there are two children placed in the home. Bedroom #1 has one twin bed, dresser, and closet space. The bedroom is occupied by child #1. Bedroom #2 has one queen bed, dresser, and closet space. The bedroom is occupied by the licensee. Bedroom #3 has one twin bed, dresser, and closet space. The bedroom is occupied by child #2. Smoke alarms were operable in each bedroom. LPA observed two bathrooms to be in good repair and working order. Sharp knives, chemicals, and cleaning supplies are kept locked in areas inaccessible to children. LPA observed a fully stocked linen closet in the hallway. The living room and dining room areas were observed to be neat with sufficient seating. LPA observed a fully stocked refrigerator in the kitchen. LPA also observed adequate perishable and nonperishable food supply stored inside cabinets in the kitchen. The front yard is enclosed entirely with a gate. The gate is accessible to enter and exit and is not obstructed or bounded by any entrance/exit restrictions. LPA observed the backyard to be free of debris and hazards. Overall, the facility appeared clean, safe, and sanitary. LPA observed fully charged fire extinguishers in the kitchen and hallway. LPA reviewed both children files and found the reviewed files to be in order. There is one camera each in the backyard, front yard, and on the side of the home. The cameras are not pointed at or towards the home. There are no cameras inside the home. The applicant has two small dogs on the premises. The dogs are allowed to roam and play in the backyard. The dogs do not stay in the home as they are kept in the garage. The garage is kept locked and has a sign posted that says, "Authorized Personnel Only." LPA observed copies of the shot records for the two dogs. Licensee has an individual license for each dog. Both licenses have an expiration date of October 19, 2026. There was one child present at the facility during the inspection. LPA spoke with the child. The child appeared neat and well groomed and indicated that things were going well. Licensee stated that there weren't any firearms or other weapons on the premises. There is adequate space for indoor and outdoor activities. Licensee stated that there were not any swimming pools or other bodies of water on the premises. The First Aid Kit was fully stocked with bandages, band-aids, scissors, tweezers, and thermometer. LPA observed a bulletin board in the hallway that contained the following posted on it: Facility License, Personal Rights information, Grievance Form, Emergency information, Facility Sketch, Rules of Discipline, and Client's Rights information. LPA also observed a fully stocked pantry in the hallway. LPA found no Title 22 deficiencies on this date. Exit interview conducted


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) T. Davis went to Wiggins Family Home on February 27, 2026 at 1:50pm in order to follow up on a Special Incident Report (SIR) that was received by Community Care Licensing on February 13, 2026. LPA met with Kendra Wiggins, licensee, and obtained additional information and documentation. Further follow up is needed

visit_type: Case Management


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) T. Davis went to the Wiggins Family Home on March 05, 2026 at 12:35pm in order to continue following up on the Special Incident Report (SIR) that was received by Community Care Licensing on February 13, 2026. LPA met with Kendra Wiggins, licensee, and conducted interviews and obtained additional information. Further follow up is needed


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) T. Davis went to Wiggins Family Home on April 10, 2026 at 12:52pm to conclude the follow up on the Special Incident Report (SIR) that was received by Community Care Licensing (CCL) on February 13, 2026. LPA met with Kendra Wiggins, licensee, and discussed the conclusion. The report stated that child #1(refer to Confidential Names form (LIC 811) dated April 10, 2026) said that the caregiver's son touched the child's backside while the family was in Florida. Information obtained shows that the licensee (811) took the foster children and her family on a family vacation to Walt Disney World in Orlando, Florida. The licensee stated that there was some friction between child #1 and child #2 as it relates to chores. The licensee also stated that she never witnessed any inappropriate interaction between child #1 and her son while in Florida. Evidence gathered indicates that both children have confirmed that there was some tension involving both children, but that things were better. Interviews with both children varied on the back and forth. The resource parent has indicated that she does not have any issues or problems with either child. The Department finds that child #1 has denied that anyone touched the child's backside. The child has also confirmed that they did not tell child #2 about anyone touching them. Child #1 feels that child #2 was upset and wanted to get back at them. The investigation also revealed that the licensee's sons have denied the allegations as well. The two children have indicated that things are fine and that they get along with one another. Based on a review of documentation, information, and other facts related to this matter, the Department finds that the situation has been stabilized and no further follow up is necessary. Exit interview conducted


facility_name: WILSON SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Linda Haynes met with applicants sister Leah Wilson Via Facetime on October 5, 2021 for a Component II. LPM went over revisions needed for the application prior to licensure. LPA gave a copy of the LIC 184, Notice of Incomplete Application, and additional correspondence to assist with the revisions needed for the application via Email. Copy of this report was provided to applicant.

met_with: Leah Wilson


summary: Facility Evaluation

raw_content:
Narrative:
On November 3, 2021 at 11: PM Licensing Program Analyst (LPA) Linda Haynes began an inspection for a Small Family Home license. LPA met with applicant Curtis Wilson who led a tour of the home. The facility was toured inside and out with the applicant. Applicant is applying for a capacity of 3 ambulatory clients. The Small Family Home is a Three bedroom and two bathroom home. There is an above ground spa. The home is set up as follows: Bedroom # The room was furnished with two beds- It will sleep two kids. Bedroom # The room consist of a queen bed and a crib Bedroom # The room consist of king bed and it sleeps the Licensee. Bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for children's belongings. There were plenty of toys for the children. The smoke detectors and carbon monoxide detectors were checked and are working properly. Telephone service and appliances were in working order. All hazardous items have been properly made inaccessible to areas where children will have access. The medication will be in locked boxes in locked cabinet in garage. Cleansers/chemicals were locked and stored in a cabinet in the garage. Sharp knives were inaccessible and stored in the cabinet in the garage as well. First Aid kit was accessible and had all required items. There were no guns or weapons as stated by Mr. Wilson at this time. The hot water temperature was tested and noted to be at 110.4 degrees. Trash cans for storage of solid waste had tight fitting lids. Personal Rights, The Facility Sketch, Emergency Disaster Plan and visitation policy were posted. The backyard was observed to be clean and free of hazards. There is a spa located in the back yard it has no water in it at this time and has a latched cover on it. There was no deficiency observed during today's visit. The home was in compliance with Title Regulation. The applicant will be scheduled for a Component III prior to licensure. The request of License will be forwarded to Licensing Program Manager for final approval. Exit interview conducted and a copy of this report was discussed and provided to applicant this date.

met_with: Curtis Wilson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Linda Haynes met with applicant Curtis Wilson Via Microsoft Teams on November 4, 2021 for Component III. LPA went over Component III powerpoint with applicant and answered questions applicant had. Copy of this report was provided to applicants a signed copy will be placed in file.


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday October 25, 2022, at 11: AM Licensing Program Analyst (LPA) Linda Haynes conducted an Post Licensing inspection of the facility. At time of inspection LPA met with Administrator Leah Wilson. The facility was toured inside and out with Administrator Leah Wilson. The home is a one-story residence with four bedrooms and two bathrooms. One client was present at time of inspection. Bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the clients bathroom was measured to be 108.6 degrees the clients do not have access to the other bathroom in the home. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the Kitchen. Cleansers / chemicals are locked and stored in locked cabinet in the locked garage. Sharp knives are inaccessible and stored in a locked cabinet in the locked garage. The First Aid Kit is located in the kitchen and contained all required supplies. The facility's smoke detectors in each bedroom were checked and were operable. The carbon monoxide detector is located in the front entrance and was operable. There are no guns or weapons in the facility as stated by Administrator Leah Wilson. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, and Visitation policies, there was no current menu posted. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is no pool or other body of water. LPA reviewed two of two client files during the inspection and one file was missing the needs and services plan the client has been in the home for 2 months. There was one client present at time of inspection. One of two clients were interviewed as one client was at school. The Licensee does not have staff. Based on the facility inspection and file reviews this date, there was one deficiency found at this time and a technical assistance note was issued. A copy of this report was reviewed and given to Administrator Leah Wilson


summary: Facility Evaluation

raw_content:
Narrative:
On December 6, 2023 at 9: AM, Licensing Program Analyst (LPA) Linda Haynes began an annual inspection for Wilson Small Family Home license. LPA met with Licensee Curtis Wilson who led a tour of the home. The facility was toured both inside and out with the Licensee. There were no clients present at time of inspection. The home is a one story building with four bedrooms and 2 bathrooms which are set up as follows: · Bedroom #1 (Master) has one bed sleeps the Licensee · Bedroom #2 (Client's) was vacant has one twin bed; it will sleep one client. · Bedroom #3 (Client's) has one twin bed; it sleeps one client. · Bedroom #4 (Guest) has one queen bed; it is vacant. · A great room/living room, kitchen, dining area, 2 bathrooms, a two car garage and the backyard. The Client's bedrooms were arranged so that no more than one client will be in the room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. There was a smoke detector in every bedroom. The four smoke detectors were checked, and they were working properly. The carbon monoxide detector is located on the wall by the kitchen and was working properly. The appliances were in working order. The client's files are locked in a file cabinet in the guest room. There was adequate food storage space. There was a two day supply of perishable foods and a week of non-perishable foods. A trash can for storage of solid waste had a tight-fitting lid. The sharp knives are in a locked cabinet in the garage. The medications are located in a locked cabinet in the guest room. The hot water in bathroom one (Master) measured to be 105.4 degrees Fahrenheit and in bathroom two 105.2 degrees Fahrenheit. The First Aid kit is located in a cabinet in the kitchen and contained all required supplies. There was one fire extinguisher present in the home it is under the kitchen sink. It was observed to be properly charged and inspected by the fire department. There is no firearm in the home as stated by the Licensee. There is no pool or other body of water present. The backyard where clients have access to play was fenced. LPA reviewed one of one client files and it contained all required documents. One of one client was not available to be interviewed LPA will attempt to interview client when they are on break from school. LPA reviewed two of two staff files and they contained all required documents. LPA interviewed two of two staff members. An exit interview was conducted. A copy of this report and appeal rights was provided to Curtis Wilson.


summary: Facility Evaluation

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Narrative:
On October 10, 2024 at 09: AM, Licensing Program Analyst (LPA) Rachel Vanegas arrived unannounced at Wilson Small Family Home (SFH) to conduct a random annual inspection of the facility. LPA met with the Licensee Curtis Wilson who led a tour of the facility which was toured both inside and out. The facility is a one story home with four bedrooms and two bathrooms which are set up as follows: Bedroom #1 (Master) has one bed and sleeps the Licensee. Bedroom #2 (Client) has one single bed and sleeps one client. It has adequate storage for personal belongings in the closet and drawers. There is adequate bedding. Bedroom #3 (Client) is vacant and has two single beds. It will sleep two clients. It has adequate storage for personal belongings in the closet and drawers. There is adequate bedding. Bedroom #4 is utilized as a staff office and stores client and staff files. Clients in care do not have access to this room and it remains locked. A living room, game/family room, kitchen, dining room area, 2 bathrooms, an attached two car garage that remains locked, and a backyard. The client bedrooms are arranged so that no more than two clients will be in one room and sleep one client per bed. No room commonly used for other purposes is used as a bedroom and no bedroom serves as a passageway to another room. There was a smoke detector in every bedroom. The smoke detectors and carbon monoxide detectors were checked and in working order. The appliances were in working order. There was an adequate two day supply of perishable food and seven day supply of non-perishable food in the kitchen refrigerator and pantry. There is an additional refrigerator and freezer, stocked with food, in the garage. **Continued on LIC 809-C** A trash can for storage of solid waste had a tight-fitting lid located in the kitchen. The sharp knives and cleaning chemicals are securely stored in the locked garage. The medications are located in a locked cabinet in the staff office. There is a small refrigerator in the staff office that stores refrigerated medication. There is an accessible first-aid kit in the kitchen cupboard near the refrigerator and the hot water temperature was measured at the kitchen sink. The hot water temperature measured at 115.1 degrees F. There are two fire extinguishers present in the home; one is located under the kitchen sink and the other is located near the garage door. They are observed to be properly charged and in working order. There are no firearms or weapons in the home as stated by the Licensee. There is no pool or other body of water present at the time of this inspection. The backyard is properly fenced, free of hazards and debris, and accessible to clients for outdoor activities and leisure. LPA reviewed one of one client files for Client 1 (C1) and it contained all required documents. One of one client was not available to be interviewed. LPA will attempt to interview client at a later date. LPA reviewed three of three staff files for Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3) and they contained documents included criminal background clearance, current CPR/First Aid certificates, training certificates, drivers licenses, employment applications, etc. Three of three staff files did not contain health screening documentation and tuberculosis (TB) examination results. The facility is issued one technical violation in accordance with California Code of Regulations (CCR) section 80010(a) for operating the facility beyond the conditions and limitations specified on the license. The facility is being cited one Type B violation in accordance with CCR (Title 22) section 80065(g)(1) for not having documentation of a health screening and documentation of a TB examination on file for S1, S2, and S3. An exit interview was conducted and a copy of this report, LIC 9102, LIC 811, and appeal rights was reviewed and provided to the Licensee - Curtis Wilson.

met_with: Licensee - Curtis Wilson


facility_name: WITMEYER SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2021 at 11: AM, Licensing Program Analyst (LPA) Zena Phillips arrived at the above facility, for the purpose of conducting a Annual inspection. LPA met Katie Durado who granted access into the facility, and tour of the entire physical plant inside and out. This facility is designed to accept ambulatory only clients. The home is set up as follows: This is two story, four (6) bedroom, four (2.5) bathroom home located in a rural neighborhood. There is a swimming pool on the premises that has a fence around the pool with a lock and a latch to make it inaccessible to the clients. There is also a patio next to the pool with a slide, swing set, bicycles, 2 play houses, lots of toys and adequate amount of seating. Downstairs (main floor) has the following: There is a living room with a sofa, and love seat, a seating that can seat two (6-8). There are 2 bedrooms with 1 half bath. One bedroom is currently being used an office. There is a storage room and a laundry room with extra refrigerator. Dining room has 6 seats with china cabinet. There is a kitchen with non-perishable foods for one week. LPA observed upper cabinets with plenty of bowls, cups, plates and storage containers. LPA observed lower cabinets have storage for plastic forks and spoons, pots & pans and additional paper plates and bowls. The drawers have adequate silverware for the current census of the home. The kitchen has dishwasher. trash compactor. The laundry room has locked cabinet for stored medicine and first aide supplies. There is pantry in the rear of the kitchen with a fully charged fire extinguisher. The home has an in ground pool with 5ft fence and alarmed if gate opens or jiggles too much. Bedroom #1: Is equipped with (1) full size bed. There are adequate drawers, closet space, and lighting. Bedroom #2: is equipped with a bed , dresser, and TV but not currently unoccupied. continued on 809 c Upstairs (2nd floor) has 3 bedroom and 2 full bathrooms. Bedroom #3: Is equipped with two (2) twin size beds. There are adequate drawers, closet space, and lighting. Bedroom #4: Is equipped with one (1) full size bed. There are adequate drawers, closet space, and lighting. Bedroom #5: Is equipped with two (2) twin size beds. There are adequate drawers, closet space, and lighting. . Bedroom #6: Is occupied by Licensee and Children in care will be supervised and protected at all times; Children will attend school, extracurricular, cultural, and personal enrichment activities. All smoke detectors were tested and are operating properly in the home at the time of visit. Carbon Monoxide alarms were tested and functional in the home at the time of the visit. The home is equipped with a sprinkler throughout the home. Facility has non-perishable foods and perishable foods for three days. Facility provides nutritious snacks between meals. Facility is clean, safe, sanitary, and in good repair. Passageways, stairways, inclines, ramps, and open porches are unobstructed. Disinfectants, cleaning solutions, and poisons are made inaccessible. There are no firearms/dangerous weapons. Temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F). Hot water temperatures are maintained between 105 and 120 degrees (F). Exit interview was conducted. A copy of this report is discussed and will be emailed to Licensee.

met_with: Katie Durado/LVN


summary: Facility Evaluation

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Narrative:
On 11/9/2023 at 10: AM, (LPA) Licensing Program Analyst - Dennis Jarmin made an unannounced visit to Witmeyer Small Family Home to conduct the required annual inspection. LPA was met by Katie Durando, DSP/LVN, who granted access to the facility. LPA then inspected the entire physical plant of the facility. The Small Family Home is licensed and the licensee prefers to serve 3 children ages 0-17 years, 2 at age of 0-2 years, ambulatory and non-ambulatory only. There are bodies of water on the premises which is a swimming pool that meets licensing requirements. The State of California license was posted. This is a 7 acres, two story home with (7) seven bedrooms and (2.5) two and half baths. There is a swimming pool on the premises with a 5 feet tall fence covering around the pool with an alarm on the gate and lever locks to prevent access. Next to the pool is the patio area with a slide and swing set, 2 small bicycles, 2 medium size play house, large amount of toys that was stored neatly, and adequate amount of seating available. 1ST FLOOR: On the first floor of the house, the main entry leads to the main living room on the front right side, which has a large sofa, love seat, recliner seat, and a piano close to a large window. The formal dining area is across from the main living room and has a long table that seat 6, and large china cabinet by another window. The house has a family and entertainment area that is equipped with a flat TV placed in front of the fireplace with a glass and screen covering. On the left side from the main room is a playroom with suitable seating equipped with love seat and recliners, additional dining area and office close to the main kitchen. The kitchen has several cabinets and knives are stowed properly and bleaches and cleaning materials are locked under the sink. There are 3-days of perishable food supply and non-perishable for 7 days, the medication cabinets are located in the kitchen locked at all times, and a large refrigerator/freezer with proper temperature gauge. LPA observed all cabinets with adequate supply of silverware, cook ware, plastic ware for the home. The kitchen has a dishwasher and trash compactor on site and a laundry room with a locked cabinet for stored medicine and first aid supplies. There is a pantry in the rear of the kitchen with a fully charged fire extinguisher and a functional carbon monoxide that is operable. Bedroom 1: (1) Full-size bed with adequate drawers, closet space, and lighting. Bedroom 2: (1) Full size bed equipped with a dresser, and TV but not currently unoccupied. Bedroom 3: (1) Not in use - but serves as an office currently 2nd Floor A large stairs that leads to a 4 bedrooms and 2 full bathrooms. Bedroom 3: (2) twin size beds with adequate drawers, closet space, and lighting. Bedroom 4: (1) full size bed with adequate drawers, closet space, and lighting. Bedroom 5: (2) twin size beds with adequate drawers, closet space, and lighting. . Bedroom 6: Is occupied by Licensee Bathrooms: (2) Clean and sanitary When there are placement, children in care are supervised and protected at all times; Children will attend school, extracurricular, cultural, and personal enrichment activities. All smoke detectors were tested and are operating properly in the home at the time of visit. The home is equipped with a sprinkler throughout the home. Facility is clean, organize, secured, sanitary, and in good repair. Passageways, walkways, stairway, and open porches are free from obstruction and debris. All windows and screens were in good repair and there are no firearms or dangerous weapons stored at the home. Temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F) and hot water temperatures are maintained between 105 and 120 degrees (F). Exit interview was conducted. A copy of this report is discussed and will be emailed to Licensee.

met_with: KATIE DURANDO


facility_name: WOLFF SMALL FAMILY HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

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Investigation Findings:
13On October 15, 2024, at 12:45 pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced visit to the Wolff Small Family Home for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA met with the licensee, and together discussed the investigation details. Based on the confidential interviews conducted with all parties involved (see confidential name list LIC 811 dated 10/15/2024) the above allegation cannot be substantiated. During the investigation, LPA Hernandez interviewed all relevant parties and accounted for their statements. However, the interviews did not yield sufficient evidence to corroborate the allegation. Even though there were some issues between Client #1 (C1) and FA, FA denied making inappropriate comments or using any form of physical punishment on C1. The interviews revealed inconsistent statements, and no witnesses were present to corroborate the alleged incident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit interview was conducted, and due to technical difficulties with the printer, a copy of this report will be emailed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez 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:

report_type: Complaint Investigation

met_with: Licensee/Else Wolff

complaint_status: unsubstantiated


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Investigation Findings:
13On 3/13/25, Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with Else Wolff and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes: law enforcement report reflecting no concerns indicated during the time of initial contact to licensee's home, written documentation from Tri-Counties Regional Center confirming receipt of serious incident report, conflicting statments from clients and staff related to the occurance of abuse, lack of eye witnesses avaialble to corroborate statements, and absence of physical markers or signs of abuse on victim's body. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nestor Gomez 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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Narrative:
Confidential statements revealed the physical assaults occurred on multiple occasions and/or occurring while licensee was either in their office or napping. Confidential interviews further determined licensee's acknowledgement of the physical assaults and that there was no clear plan in place to prevent further physical assaults on C1 by C2. Confidential statements revealed admission to not contacting the police as it was believed they would not take action due to C2 being a juvenile. Licensee ultimately requested to have C2 removed from the facility. The investigation revealed licensee was unable to provide the necessary care and supervision solely, leading to multiple incidents of C2 physically assaulting C1. Based on confidential statements and documentary evidence, the allegation claiming Licensee's neglect and/or lack of supervision led to resident being physically abused by another resident while in care is substantiated. This action poses an immediate health, safety, and personal rights risk of harm to children placed in care. Facility cited for violation of California Code of Regulations, Title Division Six, Chapter 4 regulation 83078(a)(1) Responsibility for Providing Care and Supervision. The investigation revealed licensee was unable to provide the necessary care and supervision solely, leading to multiple incidents of C2 physically assaulting C1. An exit interview was conducted. A copy of this report, the Confidential Names List and appeal rights were provided to Licensee by email. Confidential statements found denial of allegations concerning sexual abuse and further found inconsistent statements regarding alleged sexual abuse claims. Statements obtained further refute claim that Staff did not ensure minors did not have access to alcohol while in care. Based on confidential statements and documentary evidence, the allegations are 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 the California Code of Regulations, Title 22, at this time. A copy of this report was provided to the Administrator by email.

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

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: Else Wolff, Administrator


summary: Facility Evaluation

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Narrative:
On November 4, 2021 at 9:30 am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced inspection to the Wolff Small Family Home to conduct an Annual/Required inspection. LPA Hernandez met with Licensee who granted access into the home and together with Miguel A. Magana from Quality Assurance Specialist from the Tri-Counties Regional Center (TCRC) the licensee conducted a tour of the home inside and outside. The facility is a single-story family home in a residential neighborhood it has four (4) bedrooms, (2) two bathrooms, living room, kitchen, dining area, backyard, fireplace with a secured screen on attached two car garage. In addition, the home has chickens and three (3) horses. The home is licensed to serve (4) four developmentally disabled children, The annual fee is current. Currently in placement are (4) four clients from Child Welfare and Tri-counties Regional Center. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 11/04/2021. LPA observed the follow during the inspection: Bedroom #1: Is occupied by licensee and used as an office. It has one queen size bed, adequate drawer and closet space. The room has a walk-in closet and a private bathroom. Bedroom #2: Is occupied by Adult#2. It has one twin size bed, adequate drawer and closet space. Bedroom #3: Is occupied by Client#1 and Client#2. It has two twin side beds, adequate drawer and closet space. Bedroom #4: Is occupied by Client#3 and Client#4. Two twin side beds , adequate drawer and closet space. Page 1 of There is no swimming pool or any other bodies of water on the premises. The home has comfortable mattresses, clean linens, blankets, and pillows, all in good repair. The home is clean, safe, sanitary, LPA observed water damage on the floor by the sliding door of the backyard. Outdoors activity space there are pieces of wood all over the backyard, gardening tools and a hammer. LPA also observed the shed open with all the gardening tools accessible to the clients in care. The backyard houses three ponies, chickens and two dogs. LPA request vaccination card from the ponies and the dogs. Licensee will email the cards. The front yard is cleared from hazards. Clients in care are supervised and protected at all times. Facility has non-perishable foods for one week and perishable foods for two days. Facility provides nutritious snacks between meals. LPA did not observed the menu posted and the licensee stated that she was not aware about posting a food menu. Medications are locked and accessible only to employees responsible for stored medications. Facility posts child's rights in dining area adjacent to kitchen. Clients are not restricted in telephone use except by court order. Clients are accorded dignity in personal relationships with staff and others. Clients live in a safe, healthy, comfortable home and are treated with respect. Clients can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. Clients attend school, extracurricular, cultural, and personal enrichment activities. The facility has a Toyota highlander and Dodge Ram to transport clients. Current automobile insurance is with Allstate Insurance expiration date 01/10/22. Licensee stated that she will submit an exception request for the 19 year old living in the home by next week. Due to time constraint LPA will return to continue the annual/ required inspection to review personnel and clients files to ensure it meets regulatory requirements. LPA also will conduct interviews with clients and staff at a later date. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations, The following deficiencies are cited see 809D Exit interview was conducted and a copy of this report was left with the facility administrator whose signature on this form confirm receipt of this document. Page 2 of 2

met_with: LIcensee


summary: Facility Evaluation

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Narrative:
On December 13, 2022, at 10:30AM Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced inspection, at the above-listed facility, for the purpose of conducting a required annual inspection. Licensing staff was met by Facility Administrator (FA), who granted access into the facility, and provided a tour of the entire facility, inside and out. General overview: This is a one-story home with 3 bedrooms, and 2 bathrooms. It has a living room, dining room, kitchen, breakfast area, family room, garage, laundry area, front yard, and a backyard which includes 5 large sheds and horse stables. There is no body of water on site and the facility only supports ambulatory placement at this time. There are no cameras on the facility grounds. Medicines are inaccessible to children and are located in the master bedroom within the FA's locked closet area. All smoke detectors were tested and are operating properly in the home at the time of visit. There are numerous fully charged fire extinguishers available. Outdoor activity space free of obstructions. LPA measured the temperature of the water and measured within the safe temperature at 111 degrees Fahrenheit. Required signs were posted in visible sight (personal rights, license, emergency contacts). LPA observed the following during inspection: Living Room: enough seating for 6 people, tv, and no fireplace Dining Room: equipped with a large table with 5 chairs. Kitchen: equipped with a refrigerator, Cooktop - Gas, Oven, Microwave, Breakfast Nook, Continue on LIC809-C Plenty of cabinet space. Knives / Sharp objects are stored in the locked drawer near the stove and the key is secured with FA. All appliances were tested and in working condition at time of inspection. Breakfast area: consists of a counter with 3 chairs and dually functions as counter space. Garage: is being utilized to store facility vehicle and extra food items. LPA observed non perishables and a workspace area. Laundry area: equipped with a washer and dryer, and plenty of cabinet space. First aid kit was observed to be fully stocked with necessary supplies and kept in locked cabinet next to washer/dryer. Cleaning chemicals were observed to be locked in cabinet next to washer/dryer. Bedroom #1 is occupied by one client with a twin size beds on each side of the room, adequate closet and drawer space, there is a bathroom directly outside of the bedroom in good repair. Bedroom #2 is occupied by two clients it has two twin size bed, adequate closet and drawer space, there is a bathroom directly outside the room in good repair. Bedroom #3 is a master bedroom and is occupied by the FA. this bedroom has an adjoining bathroom, which is where medication is stored. Outdoor- the outdoor space is large and wraps around the facility. The entire facility is gated and completely secure. The front yard area has a garden and grass area, along with space for relaxation. The area on the east end of the property is dedicated to housing three horses that belong to the licensee (one standard, and two ponies). The back end of the property has 5 large locked sheds, which were inspected and are being utilized for storage. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations, there are no deficiencies to be cited at this time. A copy of this report was discussed with the facility administrator, and will be emailed to the facility due to technical difficulties with the LPA's printer

met_with: Elsa Wolff, Administrator (FA)


summary: Facility Evaluation

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Narrative:
On December 29, 2022, at 9:30am Licensing Program Analyst (LPA) Nancy O'Connell, conducted an unannounced Annual- Continuation inspection at Wolff Small Family Home located at the above address. Else Wolff, Licensee granted access into the facility and together conducted a file review as part of the Annual Continuation. Tri-Counties Regional Center Quality Assurance Specialist (TCRCQA), Miguel Magana was also present at the inspection. The facility is licensed to care for four (4) children, ages 0-17 years, ambulatory only (See confidential name list LIC-811 dated 012/29/2022). During the inspection, LPA reviewed 2 staff file and 2 client files. LPA found that all files maintained all required documents and are kept in separate file folders that are locked in secure location. LPA reviewed criminal background clearances for staff and all staff associated with the facility maintain a criminal record clearance as required. LPA reviewed Needs and Services Plans for residents and found that information is comprehensive. TCRCQA confirmed that the Service Coordinator conducts quarterly inspections and there have not been any concerns reported within the last year. LPA conducted interviews for a staff and a client. LPA attempted to conducted an interview for C2 but due to developmental disability, C2 was not able to engage. Per California Code of Regulation, no deficiencies will be cited at this time. A copy of this report was discussed with the staff and due to technical difficulties, a copy with be emailed to the provider.

met_with: Elsa Wolff, Administrator (FA), and Sarah Wolff, Direct Support Professional (DSP)


summary: Facility Evaluation

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Narrative:
On 12/27/23 at 09: AM Licensing Program Analyst (LPA) Jhane Haynes arrived at the above facility, for the purpose of conducting Annual/Required inspection. LPA met with Facility Administrator(FA) Else Wolff who granted access into the facility. Together FA and LPA toured the facility inside and out. This is a one-story, four bedroom 2 bathroom home located in a residential area. Two dogs and three horses are located on site. There are no swimming pool or bodies of water on the premises. LPA observed the following during facility tour: Entryway had path free of obstruction. Hallway to Client Bedrooms contained storage cabinets, bathroom with functioning toilet,sink and shower/tub combo. Extra toiletries are stored in cabinets. Bedroom #1 rooms C1 and C4. It contains two twin beds, closet, two dressers and TV. Bedroom #2 rooms C2 and C3. It contains two twin beds, closet, two dressers. Bedroom #3 rooms S1. It contains two twin beds, closet, two dressers and TV Living Room with a couch and 3 couch chairs, two fireplaces inaccessible to clients, and TV. Dining Room is equipped with shelving, table and adequate seating. Laundry contained washer and dryer, locked cabinet where chemicals are kept, LIC610 posting, cabinets with first aid, office supplies and door to the Garage. Garage contained extra food storage and storage cabinets. Has door that leads to outside. Exterior is gated all around property and contains five storage sheds, two horse barns and a vacant chicken coop. There are two picnic tables, play swing set, and garden. LPA also conducted file review of FA, S1 and all clients in care. LPA reviewed staff training, personnel record, and license. Staff associated have obtained criminal record clearance or exemption from DOJ, FBI- See LIC809-C Page 1 of 2 and CACI. LPA review client's needs and service plans, admission agreement, medical record of all clients in care. All files are maintained and contained required documents. S1, C1 and C4 were not in the home at time of inspection. LPA conducted interviews with FA, C2 and C3. The facility is clean, safe, and in good repair. No deficiencies will be cited. An exit interview was conducted and a copy of this report was left with the administrator. LIC809-C Page 2 of 2

met_with: Else Wolff


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA), Nancy O'Connell arrived at the above facility, for the purpose of conducting an Annual Random Inspection. LPA met with the licensee, Else Wolff, who granted access into the facility after LPA requested for licensee to return to facility for Annual Inspection. The licensee and LPA toured the home both inside and out. There are 2 children placed in the home. Licensee reports that she is the only adult living in the home and her adult daughter who previously resided in the home and functioned as an additional staff, moved out of the home within the last year.The facility is currently licensed to care for four (4) developmentally disabled children ages 0-17 years, Ambulatory only. This is a one story home, located in a residential area. The facility contains 4 bedrooms total. There are a total of 2 bathrooms, one of which is located in the master bedroom where licensee sleeps. During the inspection, LPA observed: knives are inaccessible to children and locked in kitchen drawer, cleaning supplies locked in cabinet in garage, medication observed to be in a locked box in the master bathroom, trash cans located in the kitchen have fitted lids, there is sufficient amount of food in the home, (perishable & nonperishable),the fireplace located in the living room is screened, there are no window bars, there is no pool or other bodies of water, caregiver confirmed there are no weapons on premises, backyard is clean and free of all debris, there is a complete First Aid Kit. Games, and recreational items are available to children in care. The temperature in the facility was observed to be within an acceptable range. There is no swimming pool or bodies of water on the premises. The facility has a backyard which contains small barns and sheds which are utilized as storages and for horses and chickens. There are horse stables on the property and licensee confirms that all parts of the facility is operated within the limitations of the license. There are two dogs in the home. Vaccinations for all the dogs in the home are current. The facility vehicle is a Toyota Sienna (2024) and LPA observed the insurance is current. Report continue on LIC809C The home is set-up as follows: Bedroom #1 - 1 queen Bed, Occupied by licensee, contains attached master bathroom where medications are locked and stored. Bedroom #2 - Twin Beds, Occupied by client #1. Contains dresser & closet space and adequate lighting Bedroom #3 - Twin Beds, Occupied by client #2. Contains dresser and closet space and adequate lighting Bedroom #4 - currently unoccupied but contains a bed, dresser/drawer and personal item. This room was previously used as staff room Living room- contains required amount of seating, tv, games, lamps. Dining room- contains table with 6 chairs and doors leading to backyard. Kitchen- stove, microwave, refrigerator, sink, island table, cabinets with tableware Laundry room- contains washer/dryer, first aide kit, exit door to garage Hallway- contains closet with fully charged fire extinguisher Garage- contains ample storage, facility vehicle Licensee provides continuous care and supervision of all clients and communicates that she only leaves the facility while the children are in school. LPA inquired about availability of additional staff in the event of an emergency and licensee reports that her other identified staff listed on the LIC500 are not available due to living far distances from the facility. LPA informed licensee that a plan would need to be developed to provide for emergency care and supervision when licensee is unavailable. LPA reviewed the LIC500 and confirmed all listed staff are reflected and have clearance. LPA obtained a copy of the facility roster and provided feedback for licensee to ensure all facility records are legible and to ensure that the facility roster is updated when clients are admitted/discharged from the facility. LPA observed the facility license and informed licensee that it must be posted in area where it can be easily viewable upon entry to facility- licensee agreed. Licensee and other adults on the LIC500 have DOJ, FBI and Child Abuse Index Checks clearance. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTER 4 there were no deficiencies noted or cited during this Inspection. Exit Interview was conducted with the licensee and a copy of this report was emailed to the facility.

met_with: Else Wolff, Licensee