facility_name: OPTIMIST VAN NUYS

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 06/30/2021 at 10:10AM (LPA) Licensing Program Analyst Rosslyn Gray made an unannounced visit to OPTIMIST VAN NUYS for the purpose to conduct Annual Required facility inspection. LPA-Gray met with facility residential Counselor who granted access to the facility and provided a tour of the entire physical plant both inside and out. The facility is licensed to care for six (6) clients, ages 13-17 years, ambulatory only; as well as three (3) 18-year-old non-minor dependents. S1 states that there is no weapons or guns on the premises. There is no pool or bodies of water on the premises. There are no security bars on the windows. There is an active alarm system, which notifies staff when any doors are open. The facility is a two story STRTP in a residential neighborhood. This is a two story home with three (3) bedrooms and four (4) bathrooms, living room, dining room, 1 staff office and 1 therapy office located down (downstairs) the living room has a non-operable fireplace with a secure screen attached. Bedrooms: All bedrooms are located upstairs, and furnished with enough lighting, drawer and closet space, comfortable mattresses, and clean linen, blankets, and pillows, all in good repair. Bedroom#1: Is occupied by Client#1 and Client#2; (one (1) minor and one (1) (NMD) Non-Minor dependent). It has two twin beds, adequate drawer adequate lighting, comfortable mattresses, clean linen, blankets, and pillows. Bedroom #2 (upstairs): Is occupied by two (2) minors Client#3 and Client#4. It has two twin beds, adequate drawer adequate lighting, comfortable mattresses, clean linen, blankets, and pillows. Bedroom #3(upstairs): Is occupied by Client#5 and Client#6; two (2) (NMD) Non-Minor dependents (. It has two twin beds, adequate drawer adequate lighting, comfortable mattresses, clean linen, blankets, and pillows. There is a full-size walk-in bathroom, walk-in closet, a balcony with and fire escape. [See Confidential Names (form LIC811), dated 06/30/2021 for names] (Continued on LIC-809C) There are four (4) Bathrooms: LPA observed one (1) staff bathroom located downstairs and three (3) full-size bathrooms upstairs; All were observed to be clean and in working order. Hot water temperatures were within safe temperatures. There is adequate linen and hygiene items. Living room: LPA observed needed repairs in the living room LPA observed several broken and missing blinds in the living rooms that need to be replaced. Kitchen and Dining area: with a six (6) chair dining table There is a microwave and refrigerator/freezer; electric stove/oven with (4) burners were operable. There is an ample supply of perishable and non-perishable food in the facility. The facility ensures three nutritious meals, snacks, and special diets. Cleaning solutions, disinfectants, and sharp knives are inaccessible to the clients (stored in a locked cabinet in the dining room on locked cabinet). The weekly menu is current and posted on the refrigerator. LPA observed covered trash cans in the dining are, kitchen, bathroom and staff office. Observed deficiency: LPA observed the refrigerator had pad locks on the upper freezer door. All smoke/ carbon monoxide detectors were tested and operable at the time of inspection. LPA-Gray observed three (3) fire extinguishers throughout the facility that were operable at the time of inspection. There is locked door that leads the laundry area equip with a Washer and dryer unit, all chemicals were locked in the upper cabinet. There is locked door that leads to the garage. LPA observed a full-size pool table, exercise equipment, two (2) additional refrigerators, one (1) freezer, pantry and storage cabinets with ample nonperishable food supplies. Staff office: All client's files and medications are stored in key locked staff office, in locked cabinets and are inaccessible to clients. All posting requirements were met and posted on the wall in the staff (regulations, licenses, emergency disaster plan and personal rights). LPA's reviewed the Clothing Inventory Log, Food Menu, and the Weight Log for all clients. LPA observed two (2) the First aid kits that in compliance. The passageways and porches are unobstructed. Backyard: The front yard and portions of the back yard were free and clear of debris. Clients can use the telephone unless restricted by court order. Clients in care are always supervised and protected. Clients are accorded dignity in personal relationships with staff and others. Clients live in a safe, healthy, comfortable facility and are treated with respect. Clients attend school, extracurricular, cultural, and personal enrichment activities. Clients can contact Community Care Licensing or Foster Care Ombudsman office in confidence without threats or punishment. Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. A review of Facility's Personnel Report Summary on 06/30/2021, indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 3, There was deficiency observed and cited (see D page). Exit Interview was conducted with S1 and a copy of this report was left with S1

Deficiencies:
80076: 1
2
3
4
5
6
7Facility will ensure that the refrigerator in not locked and is available for clients to be able to access food at alll times.

met_with: STAFF #1 YOUTH CARE COUNSELOR

title: (a) (4)Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician. This requirement is not met as evidenced by


state: CA

facility_name: OUR HEALING CENTER

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 10/15/2024 at 2:00pm Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced inspection to Our healing Center for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA spoke with Facility Administrator, Maricela Romero and together, discussed the investigative finding. During the investigative process by Licensing program Analyst (LPA), Jhane Haynes,all relevant parties have been accounted for. During the investigation LPA Haynes interviewed and accounted for all relevant parties. Based on interviews conducted, Interviews reflect youth struggles with hygiene due to developmental disability that is being addressed in weekly goals. Program provides incentives when prompted to complete hygiene. Youth was observed to meet basic hygiene. LPA Haynes did not obtained statements to corroborate the above allegations. Although the allegations 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. 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: Facility Adminstrator/Maricela Romero

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On 11/7/2024 at 1:15pm, Licensing Program Manager (LPM) Enrique Hernandez made an unannounced inspection to Our Healing Center to conclude the investigation on the above allegation and deliver the findings. LPM spoke with Facility Administrator Maricela Romero and discussed the investigative findings together. During the investigation LPA Haynes interviewed and accounted for all relevant parties. Based on the interviews conducted, the facility maintains continuous oversight of the youth under its care. The staff closely monitors the individuals to ensure their safety and well-being when leaving the facility. Additionally, due to the specific behavioral needs exhibited by some of the youth, the facility has even proposed implementing one-on-one supervision for those individuals. This approach aims to provide tailored support and address their unique challenges more effectively. LPA Haynes did not obtained statements to corroborate the above allegations. Although the allegations 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. 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:

met_with: Facility Administrator /Maricela Romero


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

raw_content:
Narrative:
Confidential interviews and documentary evidence revealed several youths at Our Healing Center engage in the use of drugs and alcohol while at the facility. Corroborating statements found the facility has had issues with youth using drugs and alcohol while in care, including marijuana, vaping and on July 7, 2024, facility reported a medical emergency as youth was reported to have overdosed on fentanyl. Confidential interviews and documentary evidence further revealed acknowledgement that a former youth resident engaged in sexual interactions with one or more youth residents while in care. Documentary evidence reveals between May 2024 and July 2024, a former resident engaged in sexual interactions with another resident. On an isolated incident, the youth was allegedly sexually assaulted by another resident while in care. Statements also revealed some residents felt uncomfortable by the former resident's sexual advances towards them. Information obtained indicates the facility Administrator promptly addressed the situation and reported the concerns to mitigate the issues upon discovery. Based on the information obtained during the investigation, claims alleging drug activity and sexual interactions on facility premises is Substantiated. Facility is cited for violation of California Code of Regulations, Title 22, Interim Licensing Standards (ILS) Version 5, Article 06. Continuing Requirements, 87065. Personnel Duties. Exit interview conducted. Appeal Rights issued.

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

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

Deficiencies:
87065.21: Supervision, protection, and care of children at all times, individually and in groups.

met_with: Maricela Romero Rodriguez, Administrator

complaint_status: SUBSTANTIATED

title:
2
3
4
5
6
7Personnel Duties Direct care staff shall perform the following duties


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 5/16/25, at 1045 am, Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA spoke with Facility Adminstrator, Marcela Romero Rodriguez and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nestor Gomez, all relevant parties have been accounted for except LPA could not get in contact with C1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occu, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was emailed to FA. 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

met_with: Monique Flores - Direc Care staff


summary: Facility Evaluation

raw_content:
Narrative:
On 523/23 at 2:30pm, Licensing Program Analyst (LPA) Christine Wilson conducted an announced Office Visit in order to review component II with the Licensee. During the Pre-Licensing Inspection at the above listed facility, Licensing Program Analyst (LPA) Christine Wilson conducted a Face-to-Face, Component Meeting with the applicant, Facility Administrator Marciela Romero, . The purpose of the meeting is to discuss the Our Healing Center, Short Term Residential Theraputic Program (STRTP) application, which had been submitted to Community Care Licensing (CCL) on April 7, 2023. The proposed facility will provide care and supervision for 6 ambulatory only children, ages 12 through 17 years old, and Non Minor Dependents (NMD) ages 18-21 years old. . LPA reviewed/discussed the children/staff forms that are required and to be maintained in the facility so that they are available for inspection. LPA informed licensee that the original Plan of Operation and Program Statement were reviewed and the following revisions will be required prior to the application being approved. The following matters were discussed: Licensing forms that need to be amended and updated (LIC401A, LIC610C, and LIC9016) LPA Wilson provided a detailed overview with feedback on the application, Program Statement and Plan of Operations. LPA Wilson also discussed revisions stated below. The following revisions have been requested: Revisions provided in detail on a separate form to Licensee: Plan of Operation B. Administrative Organization C. Facility Sketch (Continued on 809C) (Continued from 809) D. Staff Plan F. Administrative Policies and Procedures G. Admission Determination Procedures J. Removal and/or Transfer Policies and Procedures L.Handling Money, Personal Property and Valuables N.Trauma Informed Intervention and De-Escalation Techniques Q. Continuous Quality Improvement Program Statement 1. Population to be Served 2. Emergency Disaster Response Services 3. Transportation Arrangements 4. Core Services and Supports 5. Culturally Relevant Interventions, Practices, Services and Supports Other Additional Information Required: -Nursing Services LPA Wilson provided (2) Foster Youth Bill of Rights and (2) Foster Youth Rights Handbooks and (1) Foster Youth Bill of Rights Coloring Book Should this information not be received by June 22, 2023 this application will be considered withdrawn. Exit interview conducted and a copy of this report was emailed to the Applicant.

report_type: Facility Evaluation

met_with: Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5/23/23, at 12:20pm Licensing Program Analyst (LPA) Christine Wilson conducted an announced pre-licensing inspection at the above-listed facility. Licensing staff was met by Facility Administrator, Maricela Romero. The facility is one-story home which contains three (3) bedrooms, and two (2) bathrooms. The home has a fully equipped kitchen and a spacious living room, and sun room, that can be utilized as a multipurpose room. The front yard, and backyard was observed to be secure with a cinder-block fence 5.5ft in height , free of obstructions, and neat. The facility maintains one facility vehicle, Toyota Sienna LE, that seats 8 people and insurance/registration were observed to be current. All seat belts are in working order.. There is one (1) charged fire extinguisher through the facility. (2) Carbon monoxide and (4) smoke detectors were tested and fully functioning. Detergents and cleaning supplies were observed to be locked and inaccessible to minors. Medication closet was observed to be secured and inaccessible to minors. Facility files will be maintained within the staff office. LPA observed the following during inspection: Kitchen: equipped with a stove, microwave, oven, refrigerator, plenty of cabinet space, and enough plates/cups/utensils for all clients. Trash cans are covered. Dishwashing machine is not in working order and will not be used. Dining Room: there is a dining table adjacent to the kitchen with enough seating for (6) with cabinet space. Living Room: the living room is a large open space that functions as a area for relaxation, and is attached to a sun room, with plenty of seating for 10+ people, tv, a non-functional fireplace, and access to the backyard. Hallway: The hallway has a (2) linen closets and maintains enough linen and towels for all residents. There is a working smoke detector and a carbon monoxide detector in this space. Bathrooms- there are two (2) bathrooms through the facility, each with operational plumbing and running water that meets temperature requirements. (Continued on 809C) Bedroom #1: will be occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There is adequate closet and (2) drawers. There is a functioning smoke alarm. The bedroom does not serve as a passageway to any other part of the facility. Bedroom #2: will be occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There is adequate closet and (2) drawers. There is a functioning smoke alarm. The bedroom serves as a passageway to the backyard of the facility through a sliding door, which is indicated on the facility plan as an emergency exit. Bedroom #3 :will be occupied by two clients and maintain two twin beds, There is adequate closet and (2) drawers. There is a functioning smoke alarm., and an attached bathroom. Garage Space- the garage has been converted to a small room that is only large enough for storage. Licensee communicates that it was converted to include the adjacent staff office to a office activity space and provided LPA with a copy of the building permit. Laundry: located in the garage area and equipped with a washer and dryer in working order, and plenty of cabinet space. Laundry detergents and cleaning supplies are kept in locked cabinet adjacent to the laundry appliances and are inaccessible to clients without supervision. This area also functions to hold locked storage space for sharps, cleaning supplies, hygiene supplies and extra linen. Backyard - there is an enclosed cinder-block fence that extends around the perimeter of the facility that meets height requirements. There is no body of water on the premises. The yard appeared clean and orderly with no hazards. Medication station- medications will be stored in a locked cabinet, in a closet in the staff office. The policy for medication administration will be posted on the inside of the door and was reviewed by LPA. Medication boxes were kept locked within the locked cabinet, with a standard key lock and Licensee agrees to obtain and utilize a lock and key for meds. Staff office- this office is located near the kitchen and has computers, desks, chairs. This space will be utilized for staff to conduct administrative duties, and where client records will be stored. LPA observed that door does lock. There is no additional bathroom designated for staff. Licensee indicates that Bathroom #1 will be used by staff and clients. An exit interview was conducted, and a copy of this report was discussed emailed to the licensee.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2023 at 9:20 am Licensing Program Analyst (LPA) Christine Wilson, held a TEAMS meeting with Licensee, Our Healing Center for the purpose of conducting a Component III meeting. LPA Wilson virtually met with the Representative Facility Administrator (FA). LPA Wilson reviewed/discussed the children/staff's forms that are required, and to be maintained at the Facility so they are available for inspections. LPA Wilson went over the Child's Records documents, placement appraisal information LIC603, Appraisal/Needs and Service Plan LIC625, Physician Report For Community Care Facilities LIC602, Identification and Emergency Information LIC601, Admission Agreement Guide for Residential Facilities LIC604, Personal Rights Children's Have the Rights LIC613B, Record Of Client's/Resident's Safeguarded Cash Resources LIC405, Client/ Residential Personal Property and Valuables LIC621, Consent For Emergency Medical Treatment Children's Residential Facilities LIC627B, Unusual Incident Report LIC624, Centrally Stored Medication and Destruction Record LIC622. LPA Wilson also reviewed/discussed the Personnel records, Health Screening Report, Facility Personnel LIC503, Personnel Record LIC501, Criminal Record Statement LIC508, Employee Rights LIC 9052, Statement Acknowledging Requirement To Report Child Abuse LIC9108, Child Abuse Central Index Check For State Licensed Facilities LIC198A, Designation Of Facility Responsibility LIC308, Personnel Report LIC500, Criminal Record Exemption Transfer Request LIC9188, Criminal Background Clearance Transfer Request LIC9182, Applicant/Licensee Rights LIC9058, Appeal Procedures For Applicants/Licensee LIC9058, and provided the relevant regulatory reference as questions arose. Facility representative was informed that the license can be obtained within 90 days. Note: Should additional/revised documents be requested, a revised Program Statement will be submitted to LPA-Christine Wilson within a week of the request. Orientation/Application Process Certificate of Completion was signed by licensee, and sent a copy sent to LPA Wilson. A copy of this report was sent to the representative following today's meeting.

met_with: Facility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 03/25/24 at 10: Licensing Program Analyst (LPA) Jhane Haynes and Licensing Program Manager (LPM) Kevin Sauk made an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection. LPA met with Facility Administrator (FA) Maricela Romero Rodriguez who granted access to the facility and provided a tour. This is a three bedroom, two bathroom home is a residential location. LPA and LPM observed the following: Entry contained postings such as personal rights, facility sketch and disaster plan and closet where non-chemical supplies are stored. Hallway contains an empty linen cabinet, thermostat with temperature no more than 80 degrees, cabinet for accessible first aid and first bathroom. Bathroom #1 contains functional toilet, sink and tub/shower combo with additional storage. Bedroom #1 rooms C5 and C2. It is equipped two twin beds, two dressers and closet. Bedroom#2 is the master bedroom and rooms C1 and C4. It is equipped with one twin and one full bed, two dressers and an ensuite bathroom with functioning toilet, sink and stand alone shower. Bedroom #3 rooms C3 and C6. It is equipped with two twin beds, two dressers and closet. It has an exterior exit. Living room is equipped with a TV, two coffee tables and adequate seating for clients. There is a bookshelf with client activities. Activity Room contains two couches, bookshelf, TV and game console. Clients use this room to take private calls or play games. There is an exterior exit. Kitchen/Dining is equipped with adequate dishes for client use, functional appliances. Fridge contains perishables for up to two days, operating at temperature no greater than 40 degrees and 0 degrees in the freezer. Menu is posted with alternative options. Pantry contained non-perishables for up to a week. There are snacks available for in between meals and adequate seating for meal times. (Continue on LIC809-C) Exterior contains three locked storage sheds, outdoor trash cans, recycling and compost bins. There are seating and gazebo for client leisure. The are two company vehicles used for transporting clients. Vehicle insurance and registration are current and vehicles are operating in safe conditions. Staff Office contains seating, secured medicine cabinet, and additional storage room. Storage room is equipped with washer and dryer, staff only fridge, locked cleaning supply cabinet with chemicals. There is a first aid kit equipped with required dressings including but not limited to bandages, tweezers, scissors, and thermometer. There is a secured hygiene cabinet, secured cabinet where sharps and batteries are kept. There are two locked storage cabinets for clients. Staff and client files are secured in a cabinet. There is a half garage storage that is accessible from the exterior that extra clothes, shoes and activities are stored. In addition, LPA observed disaster plan, monthly emergency drill log and medication log. LPA and LPM observed a non-operational camera in the front-left corner of the house. Due to time constraints LPA will return to complete file review. No deficiencies will be cited at this time An exit interview was conducted, and a copy of this report was emailed with facility administrator.

met_with: Maricela Romero Rodriguez Facility Adminstrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 04/09/24 at 01: PM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting a case management inspection for an incident received by the department on 03/27/24. Client allowance is held to prevent possible purchases of contraband. LPA met with Residential Counselor(RC) Kira Williams who granted access to the facility. LPA conducted interviews with S1 and C1 . LPA obtained client/staff roster and picture of privilege system. Further investigation is needed to determine whether a violation occurred. There are no deficiencies to be cited today. An exit interview was conducted and a copy of this report will be emailed to the facility administrator.

visit_type: Case Management

met_with: Kira Williams Residential Counselor(RC)


summary: Facility Evaluation

raw_content:
Narrative:
On 04/25/24 at 09: AM Licensing Program Analyst (LPA) Jhane Haynes arrived at the above facility, for the purpose of continuing post-licensing inspection. LPA met with facility administrator(FA) Maricela Romero who granted access into the facility. LPA Haynes reviewed files of FA, S2, S3 and 5 out of 6 clients in care. Files are stored in locked cabinet in staff office. LPA observed staff files to contain required TB clearance, first aid certifications and records of training not limited to: medications, pro-act and mandated reporter training. All staff have obtained a criminal record clearance with DOJ, FBI, and Child Abuse Response. LPA also reviewed client files containing the immunization record, needs and service plan and intake documentation. LPA conducted interviews with FA, S2, C3, C4 and C6. No deficiencies will be cited at this time. An exit interview was conducted and a copy of this report was emailed to the administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/25/24 at 09:00AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of concluding a case management inspection for an incident received by the department on 03/27/24. Client allowance is held to prevent possible purchases of contraband. LPA met with facility administrator(FA) Maricela Romero who granted access to the facility. LPA conducted interview with FA and C1, C2, C3. At this time, the department has determined no violation has been found. There are no deficiencies to be cited today. An exit interview was conducted and a copy of this report will be emailed to the facility administrator.

met_with: Facility Administrator(FA) Maricela Romero


summary: Facility Evaluation

raw_content:
Narrative:
On 06/13/24 at 11:10AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting a case management inspection regarding the incident report received on 06/04/24.Youth engaged in inappropriate behaviors in facility. LPA met with Facility Administrator(FA) Maricela Romero who granted access to the facility. LPA conducted an interview with FA. LPA was unable to conduct interview with C1 due to absconding during visit. At this time, it has determined that no violation has been found. C1 has been provided with 1:1 support by county request and additional therapeutic services. There are no deficiencies to be cited at this time. An exit interview has been conducted and a copy of this report was emailed to the facility administrator.

met_with: Maricela Romero Facility Administrator(FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 12/18/24, at 10:00am Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced Annual inspection at the above-listed facility. LPA was met by Facility Administrator, Maricela Romero Rodriguez. The facility is one-story home which contains three (3) bedrooms, and two (2) bathrooms. The home has a fully equipped kitchen and a spacious living room, and sun room, that is utilized as a multipurpose room and individual therapy room. The facility maintains two facility vehicles, a Toyota Sienna LE, that seats 8 people and a Toyota Corolla that seats 5, All insurance/registration were observed to be current. There is one (1) charged fire extinguisher, (2) carbon monoxide detectors, and functional smoke detectors throughout the facility. All detectors and alarms were tested and fully functioning during the time of inspection. Detergents and cleaning supplies were observed to be locked and inaccessible to minors within the staff office. Sharps are stored within a locked cabinet within the staff office and inaccessible to minors. Medication closet was observed to be secured and inaccessible to minors. Facility files are maintained within the staff office. LPA observed the following during inspection: Kitchen: equipped with a stove, microwave, oven, refrigerator, plenty of cabinet space, and enough plates/cups/utensils for all clients. Trash cans are covered. Dishwashing machine is not in working order and will not be used. Dining Room: there is a dining table adjacent to the kitchen with enough seating for (6) with cabinet space that store non-perishables, and breakfast food. Living Room: the living room is a large open space that functions as a area for relaxation, and is attached to a sun room, with plenty of seating for 10+ people, tv, a non-functional fireplace, and access to the backyard.The living room rug showed stains a licensee reports that the rug is scheduled for replacement. Hallway: The hallway has a (2) linen closets and maintains enough linen and towels for all residents. Extra clothes and shoes are kept for client needs. There is a working smoke detector and a carbon monoxide detector in this space. Bathrooms- there are two (2) bathrooms through the facility, each with operational plumbing and running water that meets temperature requirements. LPA observed dust and debris in the bathrooms, and licensee reports that she will instruct the staff to clean the bathroom more frequently. (Continued on 809C) Bedroom #1:occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There is adequate closet and (2) drawers. There is a functioning smoke alarm. The bedroom does not serve as a passageway to any other part of the facility. Bedroom #2: occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There is adequate closet and (2) drawers. There is a functioning smoke alarm. The bedroom serves as a passageway to the backyard of the facility through a sliding door, which is indicated on the facility plan as an emergency exit. Bedroom #3 :occupied by two clients and maintains two twin beds. There is adequate closet space and (2) drawers. There is a functioning smoke alarm, and an attached bathroom. Garage Space- the garage has been converted to a small room that is only large enough for storage. Laundry: located in the garage area and equipped with a washer and dryer in working order, and plenty of cabinet space. Laundry detergents and cleaning supplies are locked and inaccesible to clients. This area also holds locked cabinets that have staff and client files. There is a small refrigerator for client meds if needed. Backyard - There is no body of water on the premises. The yard presented with trash debris strewn on ground around yard, dusty lawn furniture, cardboard boxes, and an old dresser drawer that is intended for trash. The licensee communicated that trash is scheduled to be thrown out and staff will be directed to maintain cleanliness on a more frequent basis. Medication station- medications will be stored in a locked cabinet, in a closet in the staff office. Medication boxes were kept locked within the locked cabinet. During the inspection, LPA reviewed medication records for C1 and C2 and noted multiple documentation errors along with missing medications for C1 and C2. Licensee observed documentation errors and agreed that medication is being incorrectly logged. She communicated that she will work with her nurse to ensure medication logs are maintained. Staff office- this office is located near the kitchen and has computers, desks, chairs. This space will be utilized for staff to conduct administrative duties, and where client records will be stored. LPA observed that door does lock. There is no additional bathroom designated for staff. Licensee indicates that Bathroom #1 will be used by staff and clients. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, there are two deficiencies to be cited at this time. An exit interview was conducted, and a copy of this report was emailed to the licensee.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 3/19/25 at 10:00am, Licensing Program Analyst (LPA) Nancy O'Connell, made an unannounced Annual- Continuation inspection to the above-listed facility, and met with the Facility Administrator (FA), who granted access to the facility. The purpose of this inspection is to conduct an Annual- Continuation inspection. During the time of inspection, LPA O'Connell reviewed the Operations, Disaster Preparedness, and Emergency Interventions sections of the Care Tool. LPA O'Connell conducted staff and client record reviews for FA, S1, and S2. LPA also conducted staff and client interviews for C1 and C2 [See Confidential Names form (LIC811), dated 3/19/25, for names]. Additional clients were not for interview. PER California Code Regulation, there are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was sent to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On June 17, 2025 at 9: AM Licensing Program Analysts LPA, Kenrick Ellis made an announced visit to Our Healing Center STRTP to conduct the Psychotropic Case Management Medication Inspection. LPA conducted a Health and safety risk assessment upon arriving at the facility. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA Kenrick Ellis met with the Administrator, Mariecela Rodriguez and conducted a brief walk through of the physical plant inside and out. LPA reviewed 3 client files and conducted 2 client interviews at the facility. One client declined to be interviewed. One client has been at the facility for less than one month. One client does not take psychotropic medications. One client is a non- minor dependent. LPA reviewed three staff personnel files on site at the facility. LPA interviewed two staff members. LPA reviewed the LIC 500 to confirm the shift which starts in the evening and ends early morning and reviewed the staff Criminal Records Clearances. The Administrator provided a physical hard copy of the psychotropic medication training topics during the training for LPA's to review. No deficiencies were cited per Interim Licensing Standards for STRTP Version 5. An exit interview was conducted, and a copy of this report was emailed to Administrator.

met_with: Mariecela Rodriguez, Administrator


facility_name: OUR SAFEHAVEN, INC.

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. There is one citation, per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report left with Facility Manager Jessica Reyes, whose signature on this form confirms receipt. Although the allegation may have happened or is valid, based on the LPAs' observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report left with Facility Manager Jessica Reyes, whose signature on this form confirms receipt.

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: Facility Manager Jessica Reyes


raw_content:
Investigation Findings:
13On 1/25/23 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at listed facility and spoke with Carole Blanchard, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA Ng reviewed documents and conducted interviews with clients and staff. Based on the interviews, it was not confirmed whether or not minor was physically assaulted in care. In addition to the confidential interviews, LPA also reviewed facility incident reports and found that facility staff knocked on the door upon entering minors' room. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that staff physically assaulted a minor in care. Therefore, the above allegations are unsubstantiated. Exit interview was conducted and a copy of the report was given to Carole Blanchard, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Carole Blanchard, Jessica Reyes


raw_content:
Investigation Findings:
13On 1/25/23 and 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at listed facility and spoke with Carole Blanchard, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During investigation, interviews were conducted, and incident reports were reviewed, and it was determined that staf verbally abused client in care. Based on LPA's interview with staff, client, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation, Staff verbally abused client in care is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80072(a)(1) Personal Rights. Please refer to attached 9099D. At this time, one deficiency was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Carole Blanchard, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., Suite San Bruno, CA Facility Name: Our Safehaven, INC.FACILITY NUMBER: 015650080

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:


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 2/22/23 at 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at listed facility and spoke with Jessica Reyes, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, interviews were conducted, and incident reports were reviewed, and it was determined that minors engaged in inappropriate behavior while in care and had access to alcohol. Based on LPA's interview with staff, clients, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation, Minors engaged in inappropriate behavior while in care and minors had access to alcohol is found to be SUBSTANTIATED. No citations were given due to facility following their emergency intervention protocol and having a safety plan set in place. At this time, no deficiencies was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Jessica Reyes, Facility Manager. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Jessica Reyes


raw_content:
Investigation Findings:
13On 9/11/23 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at listed facility and spoke with Jessica Reyes, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA Ng reviewed documents and conducted interviews with clients and staff. Based on the interviews, it was not confirmed whether or not facility staff forced youth in care to take drugs. In addition to the confidential interviews, LPA also reviewed medical records and found no evidence of staff handing that youths' medication nor the youth being on medication. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff forced youth to take drugs. Therefore, the above allegations are unsubstantiated. Exit interview was conducted and a copy of the report will be emailed to Jessica Reyes, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Although the allegation may have happened or is valid, the preponderance of evidence has not been met and there is no consistent evidence to support the allegation listed above. Therefore, the allegation is Unsubstantiated, and no deficiencies were observed. An exit interview was conducted and a copy of this report was given to Executive Director, Crystal Landa, whose signature on this form confirms receipt of these documents.

Investigation Findings:
13On 07/31/2024 at 11: AM, Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced visit to Our Safehaven. The purpose of this visit was to deliver the findings for the allegation listed above. LPA Cardeno met with Executive Director, Crystal Landa, who facilitated the inspection. There were 2 clients present at the facility during the time of the inspection. At 11: AM, LPA did a walk-through of the facility facilitated by Crystal Landa, including a brief peek into client bedrooms and observed the kitchen and refrigerator. During the course of the investigation, LPA Cardeno reviewed documents including incident reports and conducted confidential interviews with C4 and staff from a previous Case Management visit conducted on 07/23/2024. According to confidential interviews and record review, LPA Cardeno concluded the allegation, "Staff did not seek medical attention for child's injuries," is Unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Jasmine Cardeno LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: Our Safehaven, INC.FACILITY NUMBER: VISIT DATE: 07/31/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Crystal Landa, Executive Director


raw_content:
Narrative:
An exit interview was conducted and a discussion and a copy of this report along with Appeal Rights was given to Facility Manager, Jessica Reyes.

Investigation Findings:
13On 08/15/2024 at 11: AM Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced visit to Facility Our Safehaven. The purpose of this visit was to inform the facility representative of the findings for the allegation above. LPA met with Facility Manager, Jessica Reyes, who assisted with the inspection. During the course of the investigation, LPA conducted confidential interviews, record review, and walkthroughs of the facility. LPA concluded that the allegations, "Staff do not prevent the minors from having access to vape pens," and "Staff do not prevent the minors from engaging in physical altercations," had inconsistent support. Although the allegations may have happened or is valid, the preponderance of evidence has not been met and there is no consistent evidence to support the allegations listed above. Therefore, the allegations are Unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Jasmine Cardeno LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: Our Safehaven, INC.FACILITY NUMBER: VISIT DATE: 08/15/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Facility Manager, Jessica Reyes


summary: Complaint Investigation - Unsubstantiated - 5 allegations

raw_content:
Narrative:
At this time, Type B deficiencies were cited, regarding the discussions above. The facility is being cited for Interim Licensing Standards (ILS) 87072(c)(1), 87072(c)(10), and 87072(c)(15) for Personal Rights violations. Refer to LIC 9099-D pages. In addition, LPA issued Technical Assistance as an advisory to conduct more staff training. An exit interview was conducted and a discussion and a copy of this report along with Appeal Rights was given to Facility Manager, Jessica Reyes. At this time, LPA issued Technical Assistance as an advisory to conduct more staff training regarding the allegation, "Staff do not prevent the minors from wandering the facility." Refer to LIC 9102 - Technical Assistance page. An exit interview was conducted and a discussion and a copy of this report along with Appeal Rights was given to Facility Manager, Jessica Reyes.

Investigation Findings:
13On 08/15/2024 at 11: AM Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced visit to Facility Our Safehaven. The purpose of this visit was to inform the facility representative of the findings for the allegations listed above. LPA met with Facility Manager, Jessica Reyes, who assisted with the inspection. During the course of the investigation, LPA conducted confidential interviews, record review, and walkthroughs of the facility. Based on confidential interviews, record review, and observations the preponderance of evidence standard has been met. LPA concluded that the allegations, "Staff are retaliating against a minor," "Staff are not providing a minor privacy," and "Staff do not prevent a minor from being mistreated while in care," are Substantiated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Jasmine Cardeno LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: Our Safehaven, INC.FACILITY NUMBER: 015650080

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
An exit interview was conducted and a discussion and a copy of this report along with Appeal Rights was given to Facility Manager, Jessica Reyes.

Investigation Findings:
13On 08/15/2024 at 11: AM Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced visit to Facility Our Safehaven. The purpose of this visit was to inform the facility representative of the findings for the allegations listed above. LPA met with Facility Manager, Jessica Reyes, who assisted with the inspection. During the course of the investigation, LPA conducted confidential interviews, record review, and walkthroughs of the facility. LPA concluded that the allegations, "Staff does not ensure minors are prohibited from smoking on the facility grounds," and "Staff does not ensure the facility is kept free of mal odors for clients in care," had inconsistent support. Although the allegations may have happened or is valid, the preponderance of evidence has not been met and there is no consistent evidence to support the allegations listed above. Therefore, the allegations are Unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Jasmine Cardeno LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: Our Safehaven, INC.FACILITY NUMBER: VISIT DATE: 08/15/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Investigation Findings:
13Licensing Program Analysts (LPA) Shikya Belfield and LPA Omar Sawyer conducted an unannounced inspection to the above facility on 5/29/2025 at 9: AM. The purpose of this inspection is to inform the facility representative of the findings for the allegation above. LPA met with Facility Manager Jessica Reyes who assisted with the inspection. Based on confidential interviews conducted and supportive documentation to include but not limited to, staff schedules, client rosters, staff shift logs, CFT meeting notes, and client needs and service plans. Clients actively engaged in bringing alcohol and drugs in the facility. Although the allegation may have occurred, there is not enough of the evidence to support that staff did not prevent the use of drugs in the facility. Therefore, this allegation is Unsubstantiated. No violations were cited during this inspection. An exit interview was conducted, and a copy of this report was left with Facility Manager Jessica Reyes whose signature confirms receipt of this report. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Facility Evaluation

raw_content:
Narrative:
At 2:30PM, Licensing Program Analyst (LPA) Madi Fremont met virtually with the home above over Microsoft Teams for the purpose of conducting a Regional Office-initiated office meeting with the licensee. The purpose of this meeting was to discuss possible extension of Our Safe Haven's Provisional License (expiring 10/30/2021) pending the home's Mental Health Plan Approval by the home's host county. LPA met with Licensee/Administrator Crystal Campbell, who helped facilitate this meeting. Also in attendance were Licensing Program Manager (LPM) Helga Wong, and Department of Health Care Services (DHCS) representative Patricia Coyle. Currently in care are 4 ambulatory clients. During this meeting, attendees discussed barriers to the final facility survey and approval of Our Safe Haven's Mental Health Plan by Alameda County, which the county has stated is due to the unprecedented high volume of regularly scheduled and pandemic-deferred surveys that have taken precedence. Licensee Campbell has been in continual contact with the county, submitting required documentation and coordinating scheduling the final site certification visit. According to Licensee Campbell, the county has communicated that submitted documentation is under review, and the licensee should be contacted before the end of next week regarding scheduling the final walkthrough. Attendees also discussed ways to speed along this process, and discussed extending Our Safe Haven's Provisional License for an additional 6 months to allow for the approval process to be completed. Attendees requested the Licensee Campbell submit documentation of correspondence with Alameda County Mental Health to support the decision to extend the provisional license date. The facility shall submit a written request for extension of their provisional license, to include steps already taken for approval, and barriers to approval of their mental health plan. To be turned in by 5PM on Wednesday, 09/29/2021. At this time, no deficiencies were observed or cited. An exit interview was conducted and a copy of this report was emailed to Licensee Crystal Campbell, whose signature on this form confirms receipt. **See facility file for signed copy**

met_with: Licensee/Administrator Crystal Campbell


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Christopher Rollins made an unannounced annual inspection at Our Safehaven Short Term Residential Therapeutic Program (STRTP) Facility. LPA met with Crystal Campbell Administrator. The facility is licensed for 6 residents (all can be ambulatory) ages 12-18 and currently 3 clients reside in facility. The facility consists of 3 bedrooms (3 double occupancy rooms for clients) and 2 bathrooms. House is one level and cottage in the back that consists of two offices, conference room, therapeutic area for clients and a place where staff hold group meetings. No more than two clients to a room. At 12: PM, LPA Rollins and Administrator toured the facility inside and out. The kitchen is clean. The hot water in the bathroom and kitchen measured at 107.7 degrees F which is currently between 105 - 120 degrees. The facility has plenty of nonperishable and perishable food supply. Medication, cleaning supplies and knives are locked away. Medication logs are up to date and current. There are enough folks, spoons, plates and cups. All passageways are unobstructed. All smoke detectors are update and working. The home is clean, safe, and sanitary. There are no firearms on the property. The fire extinguisher has been checked and is up to date. There are no bodies of water on the property. LPA observed first aid kit to be fully stocked. The home is maintained at a comfortable temperature. Personal rights, floor plan, food menu and Emergency disaster forms were posted and in clear view. At 12: PM, LPA Rollins reviewed 3 client files with Administrator. LPA Rollins observed all three client files to be complete and found no deficiencies. The documentation in the clients file are complete and up to date. At 2: PM, LPA observed all ten staff files with Administrator. LPA observed all ten staff files to be complete, all correct documentation and all staff were up to date with there 40 hours of annual training for the year. At 3: PM LPA Rollins conducted staff and client interviews. During inspection, LPA receive a updated copy of the LIC Personnel Report to maintain their file current. A review of Licensing Information System on December 21, 2021 indicates that all facility staff associated to the program has DOJ, FBI and child abuse index check clearances. Per Title Regulations, no deficiencies were cited during this inspection. Exit interview conducted and a copy of the report was left at the facility.

met_with: Crystal Campbell- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/08/22 at 10: AM, Licensing Program Analysts (LPAs) Alyssa Ng and George Karkazis made an unannounced annual/required inspection to listed facility and met with Crystal Landa, Administrator. The facility is licensed for six residents, and currently in placement are 5 clients. During this inspection, 4 clients and 3 staff were present in the home. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. LPA Ng toured the facility inside and out. The home is single storied and has three double occupancy bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured degrees F. The thermostat measured 71 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in a locked cabinet. Extra linens are located in a locked closet in a bedroom. The weekly menu was posted in the kitchen. LPA's observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. LPA Ng interviewed 2 staff and 1 client. All three clients declined. LPA toured the backyard and observed it to be free from hazards. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard which is inaccessible to clients. All client records complete with all of the required documentation. Each client has their own separate binder of all required documents. Each psychotropic medication was did have its own Psychotropic Medication Administration Record (PMAR). All medications were consistent with these records. Staff has a centralized binder that contained their training, qualifications, and other personal information. LPA looked through all binders and were complete with all the required documentation. Resident and staff records were observed to be complete and the facility in compliance, with only the following exception: LPA Ng reviewed client records and saw that each client's needs and service plans and consent forms are not up to date. Administrator Crystal Landa advised that the therapist Constance Oliver has the updated needs and service plans and has the day off. Administrator told LPA Ng that she can send in the updated needs and services plan and consent form by 8/9/22 by 4: PM At this time, two technical violation and 0 deficiencies was cited. An exit interview was conducted, and a copy of this report was given to Crystal Landa, Administrator .

met_with: Crystal Landa


summary: Facility Evaluation

raw_content:
Narrative:
On 06/23/2023 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a visit to Our Safe Haven. LPA Ng was informed that an 16 year old client of the facility has passed away. LPA met with Jessica Reyes, Facility Manager. Facility got the notification of the client's passing yesterday at 3: PM from the county social worker. county social worker and the facility is unaware of the cause of death at this moment. LPA Ng collected client social worker contact information, copies of the incident reports, the client's treatment plan, needs and service plans for client, and any other information regarding the client. LPA also discussed with Facility Manager what steps the facility is taking to help staff and youth process the incident. The facility will continue to provide grief counseling to clients and staff. Facility has also provided extra support to clients by utilizing therapeutic services, etc. Facility will schedule a time to debrief and discuss the next steps for the staff, and more resources being provided to the clients. The facility will work with the county social worker to coordinate a meeting with facility to collect their belongings. LPA conducted an exit interview with Jessica Reyes, Facility Manager. Facility will provide updates on what was discussed during the debriefing meeting and when the county social worker collects the client's belongings.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/17/23 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management inspection with Our SafeHaven and spoke with Jessica Reyes, Facility Manager. LPA Ng discussed the incident that occurred on 6/22/23. After investigating the incident, CCL found that facility staff did not follow policies and procedures in notifying the Alameda County Sheriff's Department when C1 returned to the facility on 06/16/2023. Facility staff did not report C1's AWOL when C1 left on 06/21/2023 since law enforcement was never notified of C1's return on 06/16/2023. Facility Manager stated that after the incident, the facility held a meeting in regards to reporting requirements. Facility will implement a plan in place to ensure that law enforcement gets notified when a client comes back from AWOL. Regardless of how long a client comes back, a call will be placed to law enforcement. Supervisor and social worker will be notified and the call will be noted in the staff shift notes. No deficiencies were cited today. A copy of this report was given to Facility Manager Jessica Reyes.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/16/23 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility and met with Jessica Reyes, Facility Manager. The facility is licensed for six residents, and currently in placement are 3 clients. During this inspection, 3 clients and 3 staff were present in the home. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. LPA Ng toured the facility inside and out. The home is single storied and has three double occupancy bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured degrees F. The thermostat measured 71 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in a locked cabinet. Extra linens are located in a locked closet in a bedroom. The weekly menu was posted in the kitchen. LPA's observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. LPA Ng interviewed 2 staff and 1 client. One client declined the interview and one client was sleeping. LPA toured the backyard and observed it to be free from hazards. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard which is inaccessible to clients. Facility has comfortable furnishings, accommodations, and ample lighting. All client records complete with all of the required documentation. Each client has their own separate binder of all required documents. Each psychotropic medication was did have its own Psychotropic Medication Administration Record (PMAR). All medications were consistent with these records. Staff has a centralized binder that contained their training, qualifications, and other personal information. LPA looked through all binders and were complete with all the required documentation. Resident and staff records were observed to be complete and the facility in compliance. At this time, 0 deficiencies was cited. An exit interview was conducted, and a copy of this report was given to Jessica Reyes, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lisette Valenzuela made an unannounced case management inspection at the above agency on 06/18/2024 at 12: PM. LPA Valenzuela met with Jessica Reyes, Facility Manager who assisted with the inspection. LPA Valenzuela conducted a walk through of the facility. The purpose of the inspection was to conduct an interview with a current youth. Youth was not home at the time. Attempted interview was conducted. Exit interview was conducted with Jessica Reyes, Facility Manager. A copy of the report was printed, and left with Jessica Reyes, Facility Manager whose signature on this form confirms receipt. Report will also be emailed to facility email address.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lisette Valenzuela made an unannounced case management inspection at the above agency on 06/25/2024 at 11: AM. LPA Valenzuela met with Ashley Leite, Direct Care Staff who assisted with the inspection. LPA Valenzuela conducted a walk through of the facility. The purpose of the inspection was to conduct an interview with a current youth. Interview was conducted with youth. Exit interview was conducted with Jessica Reyes, Facility Manager. A copy of the report was printed, and left with Jessica Reyes, Facility Manager whose signature on this form confirms receipt. Report will also be emailed to facility email address.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/23/2024 at 12: PM, Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced Case Management inspection at the above facility. LPA Cardeno met with Facility Manager, Jessica Reyes and Facility Administrator, Carole Blanchard, who assisted with the inspection. LPA Cardeno conducted a walk-through of the facility including a brief observation of client bedrooms and the food supply facilitated by Facility Manager, Jessica Reyes. LPA Cardeno also met Executive Director, Crystal Landa. The purpose of the inspection was to conduct interviews with youth. LPA Cardeno interviewed youth C1, C4, and C5. Exit interview was conducted with Jessica Reyes, Facility Manager. A copy of the report was given to Jessica Reyes, Facility Manager whose signature on this form confirms receipt.

met_with: Jessica Reyes, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/18/24 at 12: PM, Licensing Program Analyst (LPA) Jonathan Medina made an unannounced annual/required inspection to listed facility and met with Carole Blanchard, Administrator. The facility is licensed for six residents, and currently in placement are 4 clients. During this inspection, 4 clients and 3 staff were present in the home. LPA Medina toured the facility inside and out. The home is single storied and has three double occupancy bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured at 120 degrees. The thermostat measured at 73 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in a locked cabinet. Extra linens are located in a locked closet in a bedroom. The weekly menu was posted in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. LPA toured the backyard and observed it to be free from hazards. LPA Medina reviewed both client and staff files during the inspection. It was noted that one of the client files was missing documentation of a TB test. Additionally, LPA Medina discussed with the administrator the implementation of a shared room agreement document. The inspection remains incomplete, and a follow-up visit will be scheduled. There was one deficiency cited for California Code of Regulations (CCR) 80069(c)(1). Please refer to 809-D. One Technical Assistance was issued for California Code of Regulations (ILS) 87087(e). An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Carole Blanchard - Administrator.

met_with: Carole Blanchard - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/19/24 at 10: AM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced visit to the above facility. The purpose of this visit was to complete the required annual inspection. LPA met with Crystal Landa - Executive Director, at the above facility to conduct the required annual inspection. LPA Medina reviewed the facilities operations, disaster preparedness plan, and discussed facilities core/therapeutic services. LPA Medina also conducted 3 staff and 1 client confidential interview. In the previous visit LPA reviewed staff and client files, conducted physical plant inspection, and began reviewing the disaster preparedness plan. The needs and service plan, as well as the medication list, were not found in the disaster binder but were available in the client binder. LPA Medina requested that a copy be printed and added to the disaster binder before the end of the visit, which the Executive Director promptly completed. Additionally, the complaint box had been broken by a client and had not yet been replaced. However, the Administrator successfully created a new complaint box by the end of the visit. One Technical Assistance was issued for California Code of Regulations 1565(d). Three technical Assistances were issued for California Code of Regulations 87072.2(a), 1565(e)(2), and 1565(c). Due to a technical error, the previous 809-D did not save and was re-signed during today's visit. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Crystal Landa - Executive Director.

met_with: Crystal Landa - Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
An in person informal meeting was held on June 16, 2025, at 3: PM in the San Jose Children's Residential Regional Office. The purpose of this meeting was to discuss concerns observed by the department. Present during the meeting: Licensing Program Managers, (LPM) Carolyn Flynn, LPM Joel Segura, Licensing Program Analyst (LPA) Shikya Belfield, LPA Omar Sawyer, LPA Brenda Rodriguez, Administrator Carole Blanchard, and Facility Manager Jessica Reyes. The following are topics were discussed based on concerns the department observed during past inspections: Reporting requirements: Based on observations of shift notes at the facility dated from December 1, 2024, to March 1, 2025, there were multiple incidents, including calls to law enforcement that were not reported to the department. Criminal Record Clearance: Facility was cited and received civil penalties for having staff work without being criminally record cleared on March 14, 2025. Facility was cited a second time and issued more civil penalties for allowing the same staff to work in the facility without being criminally record cleared on 5/29/2025. Lack of Supervision: Facility was cited for lack of supervision for not having proof of staff coverage for multiple shifts. During a review of staff schedule and time sheets, it was observed by LPA Belfield and Sawyer, that on at least four occasions staff were working 24 to 36 hours in a row. This is a potential health, safety or personal rights risk to the clients in care. Facility currently as two incident reports describing a lack of supervision of clients during the overnight shift. Needs and Service Plans: Plans do not meet the requirements outlined in the regulations. Plans are missing information that includes, client progress or decline, history, and current needs and services needed by the client. During this meeting a plan for compliance was discussed: TSP services were discussed and offered to the program. The program agrees to utilize TSP services, reaching out to LPA for more support for guardian and utilizing supportive services and resources available from the CDSS website. LPA will send information from the California Code of Regulations and Interim Licensing Standards regarding the needs and services plan to support program in becoming compliance. The meeting was concluded.

met_with: Carole Blanchard


summary: Facility Evaluation

raw_content:
Narrative:
On 09/16/2025 at 11:25 a.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Carole Blanchard, Administrator and Jessica Reyes, Facility Manager. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA Rodriguez used the CARE Inspection Tool. The facility currently has a census of three (3) clients. LPA Rodriguez reviewed five (5) staff files and three (3) client files. LPA Rodriguez also reviewed the disaster preparedness plan binder. LPA Rodriguez conducted two (2) confidential staff interviews. The clients were currently at school during the inspection. During the physical plant inspection, no deficiencies were found. LPA Rodriguez toured the facility inside and out. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and full-sized beds. Each bedroom has drawers for extra storage space. The client's bathroom was clean and furnished with hygiene supplies for each client. Extra linens are in a closet in the bathroom. The facility is clean, safe, and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. The weekly menu was posted. No bodies of water on the premises. All walkways were free from debris or hazards. LPA toured the backyard and observed it to be free from hazards. (continue on LIC 809-C) One Technical Assistance (TA) and one Technical Violation (TV) was issued during the inspection. Please see attached TA and TV. A copy of the TA and TV will be printed out for Carole Blanchard, Administrator. The required Annual Inspection is complete. An exit interview was conducted at 3:23 p.m., and a copy of this report was printed and given to Administrator Carole Blanchard, whose signature on this form confirms receipt.

met_with: Carole Blanchard, Administrator & Jessica Reyes, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/07/2025 at 11:45 a.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Case Management Inspection at the above-referenced facility to follow up on submitted Incident Reports (IRs). LPA Rodriguez met with Carole Blanchard, Administrator & Jessica Reyes, Facility Manager. At the time of the visit, three clients were present. Several IRs were submitted involving law enforcement contact. Upon review, LPA Rodriguez observed that the reports were missing required components related to law enforcement involvement. LPA Rodriguez discussed with the Administrator and Facility Manager the proper procedures for documenting incidents involving law enforcement contact. LPA Rodriguez provided the Facility Manager with the LIC 624-LE form for reference, along with PIN 23-02-CRP and PIN 17-04-CRP. LPA Rodriguez explained that while the facility is not required to use the LIC 624-LE form, any form used must include the same required information. No deficiencies were observed or cited during this inspection. An exit interview was conducted at 12:15 p.m., and a copy of this report was given to Carole Blanchard, Administrator & Jessica Reyes, Facility Manager.


raw_content:
Narrative:
This agency has investigated the complaint alleging staff did not provide adequate supervision resulting in minor engaging in sexual behavior with an adult. Based on IB's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, CCR 80078(a)), is being cited on the attached LIC 9099D. Deficiencies are being cited based on LPA's observation, interviews conducted, and record review(s) in accordance with the California Code of Regulations, Title 22, see LIC 9099D. An exit interview was conducted, and appeal rights were reviewed and developed with the Administrator. A copy of this report was left with the Administrator, Carole Blachard.

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

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

visit_type: Complaint Investigation


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Lisette Valenzuela and Amee Li made an unannounced case management inspection at the above agency on 12/17/2025 at 11:50AM. LPA Valenzuela met with Jessica Reyes, Facility Manager who assisted with the inspection. LPA Valenzuela and LPA Li conducted a walk through of the facility. The purpose of the inspection was to conduct an interview with a current youth. Youth was not present at the facility during the visit. Attempted visit was conducted. Exit interview was conducted with Jessica Reyes, Facility Manager. A copy of the report was printed, and left with Jessica Reyes, Facility Manager whose signature on this form confirms receipt. Report will also be emailed to facility email address.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/14/25 at 9: AM Licensing Program Analysts (LPA) Shikya Belfield and LPA Omar Sawyer conducted an unannounced inspection to the above facility. The purpose of this inspection is to conduct a case management regarding staff criminal record clearance. Based on a review of the Guardian system and staff roster and schedule at the facility and confidential interview conducted, it was observed by LPA's that there are four individuals who do not have criminal record clearance (see LIC811 dated 3/14/2025). This poses an immediate health, safety, or personal rights risk to the clients in care. Facility is being cited for violation of California Code of Regulations, Title 22, Division, Six, Section 80019(e) Criminal Record Clearance, as described on the following page LIC809D. A Civil Penalty is being assessed. Based on observations of the staff schedule and confidential interview, the facility does not have a facility manager on shift every time clients are present in the facility. This poses a potential health, safety or personal rights risk to clients in care. Facility issued a Technical Violation. During the a walk through of the facility with facility manager, LPA observed the food supply and discussed the food supply with the facility manager. The facility food supply was observed to be low where snacks should be available to clients in care. During this inspection, facility manager was able to show LPA's where more food was stored and made a plan to keep the supply in the home more accessible to clients in care. An exit interview was conducted and a copy of this report along with appeal rights, was left with facility manager Jessica Reyes.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/29/2025 at 9: AM, Licensing Program Analysts (LPA) Shikya Belfield and LPA Omar Sawyer, made an unannounced inspection to above facility and met with Facility Manger Jessica Reyes. The purpose for this inspection is to conduct a case management regarding concerns observed by the department. Present during this inspection were two staff. All clients were at school during this inspection. Based on confidential interviews conducted, between 3/20/2025 and 5/20/2025, and obtained documentation from the facility, to include, staff schedules, client rosters, client needs and service plans, mental health service notes, staff shift notes, incident reports, and staff time sheets. LPA Belfield observed that on at least three days and four different shifts, there was no proven shift coverage by staff. This poses an immediate health, safety, or personal rights risk to the clients in care. Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 80078(a) Responsibility for providing care and supervision. A civil penalty is being assessed. During a review of incident reports submitted, between 3/20/2025 and 5/6/2025, to the department, it was observed that a staff who was not criminal record cleared, continued to work at the facility. Facility was previously issued a citation on 3/14/2025. This poses an immediate health, safety, or personal rights risk to clients in care. Facility cited for a repeat violation of California Code of Regulations, Title 22, Division Six, Section 80019(e). A civil penalty is being assessed. Based on a review of staff shift notes, between 3/20/2025 and 5/20/2025, it was observed by LPA's that incidents occurred at the facility that were not reported to the department. These incidents include calls to law enforcement. This poses a potential health, safety or personal rights risk to the clients in care. Facility cited for violation of the California Code of Regulations, Title 22, Division Six, Section 80061(b) Reporting Requirements. Based on a review of staff schedules, client rosters, and employee time sheets, between January 1, 2025,, 2025 and February 28, 2025, LPA observed that on at least three occasions there was only one staff on shift with at least five clients. This poses a potential health, safety, or personal rights risk to clients in care. Facility issued a Technical Violation Advisory for Interim Licensing Standards section 87065.5(a)(1) Direct Care Staff/Child Ratios. Based on a review of the needs and services plans for clients in care between January 1, 2025 and February 28, 2025, LPAs observed that all plans are missing the required signatures. The plans were also observed to be not properly updated and missing information. Facility is being issued a Technical Advisory for the California Code of Regulations, Title 22, Division Six, Section 87068.3(a)(3), 87068.3(a)(4), 87068.3(b), and 87068.3(b)(1), Modifications to The Needs and Services Plan as described on the following pages LIC809D and LIC9106TV. Three deficiencies and four Technical Advisory notes are being issued. An Exit interview was conducted and a copy of this report along with appeal rights was left with Facility Manager Jessica Reyes, whose signature confirms receipt of this report.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On Monday 3/14/22 at 3:45PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to deliver notification of a citation related to an investigation at the facility. LPA met with Facility Manager Jessica Reyes and informed of the purpose of the visit. Safety precautions were taken, including screening call, mask-wearing, and hand-hygiene. During investigation, LPA learned that there was an incident in which resident R1 (See LIC 811, dated 3/14/22) became upset by something that staff S1 stated after possibly misunderstanding what S1 said. The incident escalated, and R1 threw apples at S1. During the incident, S2 was holding R1 back to avoid an escalated altercation, and S1 was heard by S2 and S3 over the phone stating S1 did not care about the job and asking S2 to let go of R1 to see if R1 would fight. Prior to this incident, there had been another incident between S1 and R1, and a supervision plan was put in place, which involved two staff being present so as to allow S1 to avoid all communication with R1 to not aggravate R1. However, during the incident, the second staff S2 was in the administrative office and the facility manager had left for a short while (approximately 20 minutes), which was long enough for an incident to occur. S2 intervened and notified Facility Manager by phone, who made their way back to the facility. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personnel Requirements. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Facility Manager Jessica Reyes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management inspection with Our SafeHaven and spoke with Crystal Landa, Administrator. The purpose of the inspection was to follow up on why incident reports not being submitted on time for 2021 and 2022. LPA Ng reviewed incident reports that have been sent in by the listed facility and found IR's submitted to CCL for 2021-2022. When reviewing documents for a complaint (complaint # 14-CR-20211230121455), LPA Ng found that 5 incident reports for 2021 have never been submitted to CCL. When LPA Ng was reviewing monthly temporary stay report for a different facility, LPA Ng recognized a few client's names that are residing at Our Safehaven. In the report, it says that C1 (Please refer to LIC811) AWOLed nine times in February and March. Also during an attempted visit to C1's school, LPA noticed that C2 was not at school. LPA called S1 (Please refer to LIC811) to see if C2 was at the facility. S1 said no and LPA Ng told S1 to submit an incident report within the required time frame. LPA asked the administrator why none these incidents were reported to CCL and Administrator stated she was unaware of not sending incident reports. Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 80061(b) Reporting Requirements. An exit interview was conducted, appeal rights provided, and sent to Crystal Landa, Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 2/22/23 at 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management deficiencies inspection with Our SafeHaven and spoke with Jessica Reyes, Facility Manager. LPA Ng discussed safety plans to ensure proper supervision and making sure the facility is meeting the needs for all clients. On 1/25/23, LPA did a facility walk through when opening complaint # 14-CR-20230119093202. During the facility walk through, LPA noticed the window screen for bedroom 1 on the floor. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80088 (b) Furniture, Fixtures, Equipment, and Supplies. Please refer to attached 809D. At this time, one deficiency was cited. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Jessica Reyes, Facility Manager.

Deficiencies:
80088(b): (b): (b)	All window screens shall be in good repair and be free of insects, dirt and other debris.

title:
1
2
3
4
5
6
780088(b)	Furniture, Fixtures, Equipment, and Supplies


summary: Facility Evaluation

raw_content:
Narrative:
On 3/25/2024 at 10: AM, Licensing Program Analysts (LPA) Jasmine Cardeno and LPA Vaishali Singh-Sood conducted a case management visit. LPA Cardeno and LPA Singh-Sood met with Facility Manager, Jessica Reyes, and Facility Administrator, Carole Blanchard who facilitated a walk-through of the facility. During the course of the investigation, there were 3 staff and 2 clients in the facility. LPA Cardeno and LPA Singh-Sood toured the facility and observed that there was not an adequate amount of food. Additionally, the refrigerator contained expired deli meat that was dated with an expiration date of 12/2023. LPA Cardeno and LPA Singh-Sood took photo evidence of the food deficiency including the expired meat package, the food inside of the refrigerator, and a picture of the menu. LPA is issuing a citation of 80076(a)(1) under Title 22 regulations for Food Services. See attached LIC 809-D. An exit interview was conducted, appeal rights were provided, and a copy of this report was given to Facility Administrator, Carole Blanchard, whose signature on this form confirms receipt.

met_with: Carole Blanchard, Facility Administrator


facility_name: PACIFIC LODGE CAMPUS

raw_content:
Narrative:
LPA obtained evidence that the facility met the regulation of staff to client ratio, records of photos and receipts replenishing basic hygiene products; the facility has implemented various structured programs while in placement and ensured that the children receive individual therapeutic services and resources to help the youth succeed when they transition out. LPA identified discrepancy in information reported by the child regarding lack of support, LPA obtained statements and records that the child was actively engaged in her program and successfully transitioned to independent living program. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has determined that the allegation of Neglect/Lack of Supervision and Personal Right are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 3. An it interview was conducted in person and the report was provided to the Program Supervisor on 04/27/2021.

Investigation Findings:
13On April 27, 2022 at 9:30AM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to the PACIFIC LODGE CAMPUS STRTP to conclude the investigation and to deliver the finding. During the investigation, LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the child's involved in the incident. LPA was unable to contact locate or interview RP who chose to remain anonymous. Information and records obtained revealed that there were no statements or documented evidence to support that the allegations that the facility "Facility is understaffed; Facility does not provide residents with basic hygiene products; Facility lacks structured programs for the youths", occurred. The internal Investigation revealed that, although the child was adamant that allegations in the complaint occurred; there is no evidence to support the allegations Neglect and Lack of Supervision and Personal Rights were violated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: PACIFIC LODGE CAMPUSFACILITY NUMBER: VISIT DATE: 04/27/2022

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

met_with: PROGRAM SUPERVISOR