raw_content:
Narrative:
In regard to the allegation that the facility does not provide a safe environment for C1. It was alleged that C1 was threatened by another youth and felt unsafe in the STRTP. Document review disclosed that C1 spoke with social worker, advised social worker that C1 did not feel safe and requested a new placement. In addition, C1 was relocated to another STRTP within two hours. Confidential interviews disclosed to LPA that all the clients feel safe in STRTP and staff ensure the STRTP is safe for all staff and clients. Based on confidential interviews and document review, the allegation that staff did not assist C2 with a health event in a timely manner, staff did not treat C1 with dignity and respect, C1 was bullied by C3, C4 and C5, staff did not adequately supervise residents, and facility does not provide a safe environment for C1, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were emailed to Administrator Tabitha Murray for signature. The signed report will be placed in facility file. residents and facility does not provide a safe environment for C1. In regard to the allegation that staff did not assist C2 with a health event in a timely manner, it is alleged that during the period January 10 - January 16, C2 had a seizure, C1 yelled for help two or three times and staff did not respond timely. Confidential interviews resulted in conflicting information being provided to LPA. Confidential interviews revealed that none of the clients have ever been denied medical attention in a timely manner; whereas another confidential interview revealed staff did not respond timely when another client alerted staff that C2 was having a seizure. Confidential interviews also revealed that staff was not alerted by anyone of C2's seizure but it was discovered as staff did their rounds. In regard to the allegation that staff did not treat C1 with dignity and respect, it was alleged that Staff #1 (S1) treated C1 inappropriately by rolling S1's eyes at C1, mumbling things under S1's breath, nagging C1, shutting a door in C1's face and other things to irritate C1. Confidential interviews resulted in conflicting information being provided to LPA. Confidential interviews disclosed that all clients are treated with dignity and respect by all staff at the facility; whereas another confidential interview disclosed that staff always "mistreat, single-out and make it seem like C1 is a bad person". In regard to the allegation that C1 was bullied by C3, C4 and C5, it was alleged C3 was being bullied by C3, C4 and C5 and staff did not do anything about it. Confidential interviews resulted in conflicting information being provided to LPA. Confidential interviews disclosed that C1 was not bullied by any of the other clients; whereas other confidential interviews disclosed C1 had an issue with C4 and staff conducted a conflict resolution session with both clients. In addition, a confidential interview disclosed of an incident where C1 was threatened by C5 and C4 and staff de-escalated the situation and kept C1 safe in the staff office. In regard to the allegation staff did not adequately supervise residents, it was alleged that staff did not check on C1 after C2 had a seizure. Confidential interviews disclosed that the STRTP was utilizing correct direct care staff/child ratio as regulated in STRTP Interim Licensing Standards (ILS). Confidential interviews also disclosed that staff adequately monitor clients and staff do routine checks throughout the STRTP. Confidential interviews resulted in conflicting information being provided to LPA. Confidential interviews disclosed to LPA that after C2's seizure, the Administrator spoke with C1 regarding incident and to check on C1; whereas other information received stated that staff did not check on C1 and C1 stayed in room most of that day. CSW had no issues or concerns regarding STRTP.

Investigation Findings:
13On April 30, 2021 at 3:25 p.m., Licensing Program Analyst (LPA), Cindy Hamilton met with Sojourners Haven Group Home III (STRTP) Administrator, Tabitha Murray to deliver the findings for the above stated allegations. Due to COVID-19 a tele-inspection was conducted via Facetime. During the investigation, LPA Hamilton conducted interviews with three of five clients, five staff, county social workers, and Administrator (ADM). LPA Hamilton conducted a health and safety tele-inspection of the STRTP on February 4, 2021 at 5: PM and no safety concerns were noted. LPA obtained and reviewed the facility's 15-minute log, placement agreements, needs and services plan, special incident reports, client roster and staff schedules. LPA Hamilton was unable to interview Client #4 (C4) due to C4 declined to be interviewed. Client #5 (C5) was not interviewed due to C5 was AWOL for long period and bed closed. On January 29, 2021, Community Care Licensing (CCL) received information stating that staff did not assist Client #2 (C2) with a health event in a timely manner, staff did not treat Client #1 (C1) with dignity and respect, C1 was bullied by Client #3 (C3), C4 and Client #5 (C5), staff did not adequately supervise UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Cindy Hamilton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: SOJOURNERS HAVEN IIIFACILITY NUMBER: VISIT DATE: 04/30/2021

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

met_with: Tabitha Murray, Administrator


state: CA

facility_name: SOJOURNERS HAVEN III

summary: Facility Evaluation

raw_content:
Narrative:
On 05/25/2021 at 10: AM, Licensing Program Analyst (LPA) Cheraki Davis conducted an SB Psychotropic Medication Inspection and met with Administrator Gina Melendez. The inspection was conducted via tele-inspection using video conference due to COVID-19. A virtual health and safety inspection were completed and no immediate deficiencies were observed. All files and medication documents were sent to LPA Davis on dates prior to inspection. A medication count was also conducted via video conference on this date. LPA reviewed two facility staff records and two client records for this facility. LPA began two client interviews via video conference at 11: AM LPA began two staff interviews via video conference at 10: AM. LPA conducted an exit interview with Gina Melendez, Administrator. No deficiencies are being cited at this time. LPA scanned and emailed this LIC 809 & LIC 811 to Gina Melendez, Administrator with a request for signature. Original signed copies will be placed in the facility file.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Gina Melendez, Administrator


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On July 7, 2021 at 10: AM, Licensing Program Analysts (LPAs) Cindy Hamilton, Jazmond Harris and Licensing Program Manager (LPM) Abdoulaye Traore conducted an annual inspection. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on 08/20/2020. LPAs and LPM were met at the facility by child care worker Onelda Avila. A physical plant inspection was completed at 12: PM and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in locked cabinet in the upstairs staff office. Licensee did not have provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 105 degrees. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Per facility staff, no firearms or weapons are allowed in the facility. Administrators Gina Melendez and Tabitha Murray were not present at the facility at the time of inspection. Staff schedule and staff interviews revealed that the Administrators are not at the facility for a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. The facility employs eight direct care/facility managers. A review of client records was also completed on this date and deficiencies were observed. Client #1's (C1) (see Confidential Names List, LIC 811 dated July 7, 2021) file did not have a Needs and Services Plan which poses a potential health and safety risk to clients in care. Client interviews were conducted and did not reveal any health or safety concerns. In addition, during the facility inspection the facility was unable to provide copies of the Board of Director's meeting minutes. Other deficiencies were observed: technical violations and deficiencies will be assessed. A case management inspection will be conducted at a later date to complete the annual inspection. Exit interview was conducted and deficiencies were advised.

Deficiencies:
87063(a): Accountability

(a) The board of directors or other governing body including, but not limited to, an individual natural person who is a licensee, shall be active in ensuring oversight and accountability, and shall perform, at a minimum, the following duties
87070(c): Children's Records

(c) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record

visit_type: Annual

met_with: Erica Brown, Case Manager


summary: Facility Evaluation

raw_content:
Narrative:
On July 9, 2021, Licensing Program Analysts (LPAs) Cindy Hamilton, Jasmond Harris and Licensing Program Manager (LPM) Abdoulaye Traore continued an annual inspection. The purpose of the continuance was to review the facility's staff files. LPAs and LPM was met at the facility by case manager Erica Brown. At time of previous inspection Administrators Tabitha Murray and Gina Melendez were not present and upon further record review it was determined that Administrators are not present at the facility for the required time set fourth in the Interim Licensing Standards (ILS). This poses a potential health, safety and personal rights risk to the clients in care and deficiencies will be cited. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through December 31, 2021. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained on-site in a locked cabinet in a locked downstairs closet. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Staff interviews were conducted and did not reveal any health and safety concerns. During the inspection deficiencies were observed regarding staff scheduling and files, staff training and client files. These deficiencies were cited. An exit interview was conducted and this report was explained and provided to Facility Manager Shanesha Lee.


summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2021 at 9: AM, Licensing Program Analyst (LPA) Cindy Hamilton met with Sojourners Haven Executive Director Latrese Armstrong. The purpose of this office visit was to have Executive DIrector Armstrong sign the Non-Compliance Conference Summary that occurred on August 30, 2021. A copy of this report was provided to Executive DIrector.

met_with: Latrese Armstrong, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on August 3, 2023 at AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Administrator, Sharrae Smith and inspected the facility inside and out. LPA reviewed three of child's records and three of staff personnel files on site at the facility. LPA reviewed three of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed three of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Administrator, Sharrae Smith. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator, Sharrae Smith.

met_with: Administrator, Sharrae Smith


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2023, Licensing Program Analyst (LPA) Adaleyci Caballero conducted an unannounced required 2-year inspection and met with Facility Manager III Precious Spence. LPA disclosed the purpose of the visit and was granted entry into the facility. One client and three staff were present during the inspection. The facility is a three-bedroom, three-bathroom two-story house composed of two offices, one living room, and a TV area. One out of the three bathrooms is for staff use. Facility Manager III Precious Spence accompanied LPA inside and out of the facility inspection. A physical plant inspection was completed and included the following areas: facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/games were observed for clients' recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked closet in the staff office. Licensee did have provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 113.8 degrees Fahrenheit. Facility has cameras in common areas of the facility. Administrator Latrese Armstrong is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during inspection. The facility employs one therapist, a case manager, and eleven facility managers. Licensee has obtained a Mental Health contract with San Bernadino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through May 31, 2024. LPA discussed the following with the Facility Manager III: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. Based upon the inspection, records reviews confirms that the Licensee appears to be meeting CFT and Core Services/Supports requirements. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained on-site in a locked cabinet inside a locked storage closet. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. A review of client records was also completed on this date. Client staff interviews were conducted and revealed no health and safety concerns. LPA issued a Technical Violation for 2 out of 5 clients not having results of an examination for communicable tuberculosis disease.

met_with: Facility Manager III-Precious Spence


summary: Facility Evaluation

raw_content:
Narrative:
On June 4, 2025, Licensing Program Analyst (LPA) Jacob Ortega conducted an unannounced random annual inspection and met with Facility Manager (FM) I, Breanna Silveira. One client and two staff were present during the inspection. The facility is a three-bedroom, two-story house composed of two offices, one living room, and a TV area. One of the three bathrooms is designated for staff use. FM accompanied LPA throughout the interior and exterior inspection of the facility. A physical plant inspection was completed and included the following observations: facility grounds were clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment and games were observed for clients' recreation time. All facility smoke detectors and carbon monoxide detectors were found to be in proper working order. The licensee maintains an adequate supply of perishable and non-perishable food items and appears to be following the posted menu. All required forms are posted, including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked closet within the staff office. Individual beds, which are located upstairs, were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair and ensured no more than 2 clients shared a room. The hot water temperature in the client's bathroom was measured at 112.2 degrees Fahrenheit. LPA reviewed three client files (C1-C3). All three files contained the required documentation, including signed placement agreements, client demographic information, consent for medical treatment authorization forms, needs and services plans, medical assessment clearances, and signed personal rights documents. Continued on C Page*** LPA reviewed five staff files for Staff (S1-S5).Each file contained the required documents including verification of criminal background check clearance, Child Abuse Index Check clearances, signed acknowledgment of mandated child abuse, and health screening. All staff files had the appropriate education requirements. LPA observed that C2 had taken a TB test but had not yet received the results from the laboratory, due to this a Technical Violation was cited. Due to this delay in lab results LPA informed FM that they will send via email proof that the facility has reached out to the physician following up on the lab results. At the time of inspection three staff interviews were conducted and zero client interviews were conducted due to clients refusing to be interviewed, At the time of inspection no deficiencies were noted and a copy of this report and LIC 811 was given a to Facility Manager Breanna Silveira.

met_with: Breanna Silveira Facility Manager 1


summary: Facility Evaluation

raw_content:
Narrative:
On November 25, Licensing Program Analyst (LPA) Linda Haynes met with Facility Manager III (FM) Precious Spence. LPA arrived at the facility to interview Client 1 (C1) about a previous placement. FM was given a copy of the LIC 809 and LIC Confidential Names List.

met_with: Precious Spence


summary: Facility Evaluation

raw_content:
Narrative:
On January 6, 2026, at 1:00 pm Licensing Program Analyst (LPA), Matthew Dorantes, met with Sojourners Haven III (STRTP) Facility Manager III, Precious Spence, to deliver a case management deficiencies report. Information obtained by Community Care Licensing (CCL) revealed a concern regarding the timely renewal of the facility's Administrator Certificate. On December 12, LPA became aware that Administrator Certificate had expired on 11/16/2025. Confidential interviews and record review revealed that Administrator had submitted a renewal request via the renewal portal on 12/11/2025, which is after the expiration date. This is a violation of Interim Licensing Standards (ILS) standard 87064(b): "All short-term residential therapeutic programs shall have a qualified and currently certified administrator. Confidential interviews reported a previous hard copy of the renewal request had been submitted prior to the expiration date, however record review was unable to confirm or dispute this statement. Therefore a Technical Violation is being issued to the facility in lieu of a citation. The STRTP is being issued a technical violation of ILS 87064(b) Administrator Qualifications and Duties. A copy of the report was discussed and provided to Sojourners Haven III (STRTP) Facility Manager III, Precious Spence.

met_with: Facility Manager III


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst's (LPAs) Rachel Vanegas and Emina Preciado on October 15, 2025 at 10:10am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPAs Vanegas and Preciado met with Precious Spence - Facility Manager III, and inspected the facility inside and out. LPAs reviewed one of one child records and five of five staff personnel files on site at the facility. LPAs reviewed one of one child's psychotropic medications and medication records. LPAs interviewed two of two staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed one of one children currently prescribed psychotropic medication. During the inspection the LPAs observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPAs provided a copy of this licensing report to Precious Spence, Facility Manager III. LPAs conducted and exit interview with Precious Spence - Facility Manager III.

met_with: Precious Spence - Facility Manger III


summary: Facility Evaluation

raw_content:
Narrative:
On August 12, 2021, at 12: PM, Licensing Program Analysts (LPA) Cindy Hamilton met with Administrator Gina Melendez at Sojourners Haven Group Home II to do follow-up on a Plan of correction (POC) regarding Sojourners Haven Group Home III that has not been received by Community Care Licensing (CCL). The Short Term Residential Therapeutic Program (STRTP) was cited on July 09, 2021 at 9:20 am for Training Requirements (d) Annual Training (1) Notwithstanding California Code of Regulations, Title 22, Sections 80065(f)(1) through (6), all direct care staff shall complete a minimum of 40 hours of annual training, except as specified in (2) below. When the citation was issued Sojourners Haven Group Home III, LPAs Cindy Hamilton and Jazmond Harris, and Licensing Program Manager (LPM) Abdoulaye Traore met with Case Manager (CM) Erica Brown in person and discussed that the POC was to provide CCL with copies of the completed annual training certificates and certificates be filed in individual staff files by POC due date August 9, 2021. CCL did not receive the POC. The STRTP ws cited on July 9, 2021 for Training Requirements (d) Annual Training (1) Notwithstanding California Code of Regulations, Title 22, Sections 80065(f)(1) through (6), all direct care staff shall complete a minimum of 40 hours of annual training, except as specified in (2) below. (A) At least 20 of the 40 hours of annual training shall consist of course work from an entity other than the short-term residential therapeutic program such as an accredited educational institution, workshops, seminars, or other direct training provided by a qualified individual, who meets the requirements specified in Section 87065.1(c)(4)(A)1, who is not affiliated with the short-term residential therapeutic program licensee. When the citation was issued CM and LPAs and LPM discussed the POC was to provide CCL with copies of the completed training certificates and the certificates to be filed in individual staff files by the POC due date August 9, 2021. CCL did not receive the POC. Based on the failure to correct the deficiency issued on July 15, 2021, a civil penalty of $100 per day beginning on August 3, 2021, and will continue to accrue at $100.00 per day, until deficiency is corrected. A copy of this report along with LIC Civil Penalty Assessment were provided to Administrator Gina Melendez.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst's (LPA's) Leslie Covarrubias, Jose Gonzalez, Rachel Vanegas on December 5, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA's Covarrubias, Vanegas, and Gonzalez met with Facility Manager, Precious Spence and inspected the facility. LPA's reviewed one of child's records and two of staff personnel files on site at the facility. LPA's reviewed one of child's psychotropic medications and medication records. LPA's interviewed two of staff on site to discuss the facilities policies and procedures of operation. LPA's interviewed zero of children currently prescribed psychotropic medication. LPA's will conduct interviews at school. During the inspection the LPA's observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA's provided a copy of this licensing report to Facility Manager,Precious Spence.

met_with: Precious Spence, Facility Manager


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews provided conflicting information regarding preventative measures that were taken by Staff #2 (S2) leading up to the physical altercation that occurred between C1 and C2, and if preventative measures taken were adequate for the situation. Confidential interviews provided conflicting statements regarding forms of de-escalation utilized by S2. Confidential interviews could not confirm or dispute the allegation. Based on record review and confidential interviews the allegation alleging staff did not ensure the environment was safe, healthy, and comfortable for minor in care may have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Facility Manager III, Precious Spence.

Investigation Findings:
13On February 05, 2026 at 2:30 pm Licensing Program Analyst (LPA), Matthew Dorantes conducted an unannounced visit at Sojourners Haven III Short Term Residential Therapeutic Program (STRTP) to deliver the finding for the above stated allegation. A Health and safety inspection of the facility was conducted on December 02, 2025, and no immediate hazards were observed. The investigation included interviews with four staff members (S1, S2, S3, S4), one administrator (Admin), four children (C1, C2, C3, C4) and one County Social Worker (CSW1) In addition, county and facility records were reviewed. On November 24, 2025, Community Care Licensing (CCL) received an allegation alleging staff did not ensure the environment was safe, healthy, and comfortable for a minor in care. Specifically, it was reported that Child #1 (C1) was punched in the face and stomped on their head by Child #2 (C2) inside of the facility. ***Next page continued on LIC 9099-C*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Matthew Dorantes 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: SOJOURNERS HAVEN IIIFACILITY NUMBER: VISIT DATE: 02/05/2026

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


facility_name: SOUTH COAST CHILDRENS SOCIETY-CALADIUM

raw_content:
Narrative:
2021 did note a healing scab about a half inch in diameter on the left shin of C1. Confidential interviews could not confirm or dismiss that the injury to C1's shin occurred during the restraint. Based on record review, confidential interviews and LPA observation the allegation of staff improperly restrained minor (Child #1 (C1) resulting in injury, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. Lpa N. Strickland received an email from Interim Administrator Richard Boyer authorizing Direct Care Staff Sophia Inaba to sign on behalf of the facility. An exit interview was conducted, and a copy of the report was provided along with appeal rights to South Coast Childrens Society - Caladium Direct Care Staff Sophia Inaba..

Investigation Findings:
13On July 2, 2021 at 4:13pm Licensing Program Analyst (LPA), Nicole Strickland met with South Coast Childrens Society - Caladium Direct Care Staff Sophia Inaba to provide the findings for the complaint investigation for the above allegation. The investigation included interviews with three staff (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3)), Administrator (ADM), three of six residents (Child #1 (C1), Child #2 (C2), Child #3 (C3)), and County Social Worker (CSW). In addition, county records and facility records were reviewed. On April 8, Community Care Licensing (CCL) received an allegation that staff improperly restrained minor (Child #1 (C1) resulting in injury. Specifically, it was reported that C1 had been restrained and sustained a small bruise. Record review revealed that C1 had been restrained on April 6, 2021. Record review did not notate any injuries to C1 during the restraint. Record review could not provide any documentation that C1 had an injury prior to the restraint. Confidential interviews report that the restraint was done by two staff while a third staff attempted to move items out of the area to ensure C1's safety. LPA observation on April 13, UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 07/02/2021

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

met_with: Sophia Inaba


raw_content:
Narrative:
Confidential interviews revealed that staff have not been observed causing any injury to any of the children. Confidential interviews also revealed that no staff have been observed hitting or choking any of the children in care. Confidential witness statements did reveal that staff do raise their voices to get the children's attention, but staff do not yell in a mean way. Confidential witness statements also revealed that staff have not been observed ripping any of the children's clothing. Confidential witness statements did reveal that C1 has been observed ripping C1's own clothing. During the investigation, C1 declined to provide a statement regarding the allegations. Based on confidential interviews and records reviewed, the allegations that staff caused C1 injury, staff hit and choked C1, staff yelled at C1, and staff ripped C1's clothing, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Facility Manager Melanie Brown.

Investigation Findings:
13On December 9, 2021, at 10:59am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced to the facility and met with Facility Manager Melanie Brown of Southcoast-Caladium to discuss the investigative findings for the allegations noted above. LPA conducted an inspection with the facility on July 19, 2021 at 2:47pm, no deficiencies were noted. During the investigation LPA interviewed three children (C1, C2, C3), two facility staff (S1, S2), and one confidential witness (A1). During the investigation, LPA reviewed Needs and Services Plan (NSP) for C1. On July 16, 2021, the Department received allegations that staff caused group home child injury, staff hit and choked group home child, staff yelled at group home child, and staff ripped group home child's clothing. It was reported that C1 is being mistreated by staff and that C1 sustained a scratch on C1's hand by an unknown staff member. It was also reported that allegedly a staff choked C1, and punched C1 in the face. It was also reported that a staff yelled at C1 and ripped C1's shirt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 12/09/2021

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

met_with: Melanie Brown


raw_content:
Narrative:
and specifically for the specialized population. Confidential interviews revealed that training is not provided for the specialized population of clients placed at the facility; the lack of staff training resulted in staff overstimulating the C1 and staff were not able to fully understand the needs of the C1. Review of the facility Program Statement indicated that staff are to be trained initially during the new hire process and annually regarding working with specialized populations. Facility could not provide documentation for staff training. Based on confidential interviews and record review of the facility's program statement, the preponderance of evidence standard has been met regarding the allegation that unqualified adults are caring for children is substantiated. This poses a potential Health, Safety, or Personal Rights risk to C1 in care, the facility will be cited for violating Interim Licensing Standards, STRTP Article 6, 87065.1(a)(1)(C). Supervision, Evaluation, and Training Requirements. An exit interview was conducted and a copy of this report, along with the appeal rights were explained and provided to Staci Tornquist, Program Director. approximately two weeks later due to an infection. Based on confidential interviews, initial medical attention was sought in a timely manner after C1 injured their finger; staff transported C1 to the emergency room within one hour of the injury. Confidential interviews revealed that two weeks later C1's finger was infected, and C1 was prescribed an antibiotic. Supporting interviews revealed that staff observed that C1's finger smelled and looked infected when the bandages were taken off and changed at the facility. There is no account to when the infection occurred. Based on confidential interviews, the allegation that staff did not seek medical attention in a timely manner may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, along with the appeal rights were explained and provided to Staci Tornquist, Program Director.

Investigation Findings:
13On June 29, 2022, at 9:55 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit to the facility to deliver the findings of the complaint investigation for the above allegation. LPA met with Staci Tornquist, Program Director. Licensing Program Analyst (LPA) Charmaine Linley inspected the facility on 03/17/2022 at 3: PM. No deficiencies were observed during the inspection. LPA Linley obtained and reviewed the following documents: Special Incident Reports and C1's Needs and Services Plan. Special Investigator Hector Quintanar of the Community Care Licensing (CCL) Investigation Branch Bureau conducted interviews with seven Staff (S1 - S7) and Client #1 (C1), and a School Psychologist. In addition, Investigator Quintanar obtained and reviewed the following documents: Facility Binder Logs, Urgent Care Referral form, Hospital Medical Forms, Text messages, and Photos (2) of C1's finger. On March 10, 2022, Community Care Licensing (CCL) received an allegation that unqualified adults are caring for children. It was reported that staff did not receive training in working with the clients and SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 06/29/2022

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: Staci Tornquist, Program Director


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On July 08, 2022, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at South Coast Childrens Society - Caladium and met with Omar Gomez, Facility Supervisor. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging "Staff did not administer minor's medication as prescribed." LPA Barragan spoke with staff, clients, reviewed the PMAR and other predominant documents. Based on documents reviewed, an inspection, and conversations with staff and clients, all the information that was gathered was conflicting. "Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED." An exit interview was conducted with Omar Gomez, Facility Supervisor. A copy of this report and appeal rights were provided to Omar Gomez, Facility Supervisor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Eduardo Barragan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Omar Gomez, Facility Supervisor


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed that C1 was without C1's prescription medications while a refill was being processed. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met regarding the allegation that staff are not administering medications according to physician's orders, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, 80075(b) Health-Related Services, are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report, along with the appeal rights were explained to Administrator Ethan Alli. Due to printer malfunction, this report will be emailed to Administrator Ethan Alli.

Investigation Findings:
13On March 7, 2023, at 11:53am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility and met with Administrator Ethan Alli of Southcoast-Caladium to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on October 25, 2022, at 1:16pm, no deficiencies were noted. During the investigation, LPA interviewed three facility staff (S1, S2, S3), one county social worker (CSW), and four children (C1, C2, C3, C4). LPA also reviewed Medication Administration Record (MAR) for C1 for October of 2022. On October 20, 2022, the Department received an allegation that staff are not administering medications according to physician's orders. It was reported that the facility is not giving C1 their prescribed medications. A review of the facility's MAR for C1 during October of 2022 revealed that C1's medications were not given from 10/10/2022-10/14/2022. Confidential interviews revealed that facility staff did not ensure that C1's prescriptions were refilled in time so that C1 would not miss a dosage. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 03/07/2023

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

met_with: Ethan Alli

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Confidential interviews revealed that staff made attempts at verbal interventions and redirections to prevent C1 from climbing onto the roof. Other confidential interviews stated that staff did not make any intervention attempts. Confidential witness statements resulted in conflicting information as to whether or not staff made attempts to prevent C1 from climbing onto the roof and ensure C1's safety. Based on confidential interviews, and records reviewed, the allegation that the facility does not provide a safe environment for minors in care is unsubstantiated. Meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, along with the appeal rights were explained to Administrator Ethan Alli. Due to printer malfunction, this report will be emailed to Administrator Ethan Alli.

Investigation Findings:
13On March 7, 2023, at 12:27pm, Licensing Program Analyst (LPA) Adrian Mendez made an unannounced inspection to the facility and met with Administrator Ethan Alli of Southcoast-Caladium to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on August 3, 2022, at 11:33am. No deficiencies were noted. During the investigation, LPA interviewed two facility staff [staff 1 (S1) and staff (S2)], and six children [ client 1 (C1), client 2 (C2), client 3 (C3), client 4 (C4), client 5 (C5) and client 6 (C6). LPA also reviewed one Serious Incident Report (SIR) dated 07/28/2022. On August 1, 2022, the Department received an allegation that the facility does not provide a safe environment for minors in care. It was reported that the facility's protocols prohibit staff from physically restraining children in the home which has led to C1 exiting the facility and climbing onto the roof of the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 03/07/2023

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


raw_content:
Narrative:
Other confidential witness statements revealed that C2 did inappropriately touch C1. Based on confidential interviews, the allegation that staff did not intervene when C2 inappropriately touched C1 is unsubstantiated. Meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, along with the appeal rights were explained to Administrator Ethan Alli. Due to printer malfunction, this report will be emailed to Administrator Ethan Alli.

Investigation Findings:
13On March 7, 2023, at 1:03pm, Licensing Program Analyst (LPA) Adrian Mendez made an unannounced inspection to the facility and met with Administrator Ethan Alli of Southcoast-Caladium to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on August 23, 2022, at 12:08pm. No deficiencies were noted. During the investigation, LPA interviewed two facility staff [staff 1 (S1) and staff (S2)], and six children [client 1 (C1), client 2 (C2), client 3 (C3), client 4 (C4), client 5 (C5) and client 6 (C6)]. On August 17, 2022, the Department received an allegation that staff did not intervene when minor inappropriately touched another minor in care. It was reported that C2 had inappropriately touched C1 while some of the residents went swimming. Confidential interviews revealed that C2 was not observed to inappropriately touch C1. Confidential interviews also denied that any inappropriate touching occurred. Confidential interviews also revealed that staff did redirect clients from splashing C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 03/07/2023

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


raw_content:
Narrative:
Other confidential interviews revealed that staff do not utilize the emergency intervention plan during AWOL incidents. Confidential interviews resulted in conflicting statements as to whether or not the facility followed the emergency intervention plan during the AWOL incidents. Based on confidential interviews, the allegation that staff are not utilizing the emergency intervention plan to prevent youths from multiple AWOL's is unsubstantiated. Meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, along with the appeal rights were explained to Administrator Ethan Alli. Due to printer malfunction, this report will be emailed to Administrator Ethan Alli.

Investigation Findings:
13On March 15, 2023, at 12:45pm, Licensing Program Analyst (LPA) Adrian Mendez made an unannounced inspection to the facility and met with Administrator Ethan Alli of Southcoast-Caladium to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on December 15, 2022, at 2:27pm. No deficiencies were noted. During the investigation, LPA interviewed two facility Staff (S1,S2) and six Children (C1 - C6). LPA also reviewed the facility's Program Statement and Plan of Operation. On December 13, 2022, the Department received an allegation that staff are not utilizing the emergency intervention plan to prevent youths from multiple AWOL's. It was reported that an excessive amount of absent without leave/permission (AWOL) incidents is a concern for the safety of the children in care. Confidential interviews revealed that the staff do utilize the emergency intervention plan in making intervention attempts to prevent youth from AWOLing from the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 03/15/2023

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


raw_content:
Narrative:
attempts were made, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff did not prevent C2 from inappropriately touching C1, due to lack of supervision, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Stephanie Cano. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On August 15, 2024, at 1:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Stephanie Cano, Facility Manager, to discuss the investigative finding for the allegation noted above. LPA Guadalupe Munoz conducted an inspection of the facility on December 18, 2023, at 1:00 pm and no deficiencies were observed. LPA Linley interviewed two clients (C3-4), five staff (S1-5), and LPA was unable to interview two clients (C1-2), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Client Roster, Staff Schedule, C1's Needs and Services Plan, and C2's Needs and Services Plan. On December 13, 2023, Community Care Licensing (CCL) received an allegation that staff did not prevent minor (C2) from inappropriately touching another minor (C1) due to lack of supervision. Confidential interviews revealed conflicting statements. Due to being unable to interview all individuals, although multiple UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 08/15/2024

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

met_with: Stephanie Cano


raw_content:
Investigation Findings:
On September 26, 2024, at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz met with facility representative, Crystal Martinez to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 02/21/24 at 1:30 pm and no deficiencies were observed. LPA interviewed two staff (S1-2) and four clients (C1-C4). During the investigation, the following documents were reviewed: Personnel Roster and Staff Schedule, Client Roster, Needs and Services Plan, and Special Incident Report. On 02/14/24, Community Care Licensing (CCL) received allegations that staff inappropriately handled a minor. Specifically, it was stated that C1 was pushed onto a bed by S1. Confidential interviews indicated that C1 was in crisis for a few hours and was displaying behaviors that included, aggression towards other residents and staff, property destruction, and antagonizing peers. S1 and S2 were with C1 during the crisis and had to use Pro Act techniques to evade physically aggressive behavior from C1. All interviews confirmed that C1 was in crisis that night. There were no witnesses to confirm or dispute the allegation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 4

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

met_with: Crystal Martinez


raw_content:
Narrative:
Regarding the allegation that facility did not meet the medical needs of minor in care, confidential interviews confirmed that STRTP did not have a nurse on their staff and that medication responsibilities were delegated to residential managers. Confidential interviews revealed that residential managers had may tasks and medication management and administration were not the priority. Confidential interviews and records reviewed also revealed that C1 was not being administered their medication as prescribed and approved on JV220 dated 9/14/24. On 01/24/ LPA observed medication bubble pack left at the school that had not been administered to C1 due to lack of communication from the facility. Regarding the allegation that lack of supervision of minors in care led to inappropriate sexual contact, confidential interviews confirmed that due to C1's needs they were determined to have a 1:1 staff assigned to them while living at the facility. Confidential interviews and records reviewed also confirmed that on the night of the incident C1 was not assigned a 1:1 staff. In addition, records reviewed, and interviews conducted also confirmed that facility did not follow 1:1 supervision protocol and left C1 and C2 unsupervised which resulted in C1 being the victim of inappropriate sexual contact by C2. Based on confidential interviews, the preponderance of evidence standard has been met and the allegations that facility did not meet the medical needs of minor in care and that lack of supervision of minors in care led to inappropriate sexual contact are substantiated. The STRTP facility is being cited for violation of the and Interim Licensing Standards Version 5, Article 06. Continuing Requirements 87075(c) Health Related Services and Section 80078(a) Responsibility for providing Care and Supervision. An exit interview was conducted, appeal rights were explained, and a copy of this report and LIC 811 dated 06/10/25 were provided to facility designee. Confidential interviews also revealed that C1 does not like to bathe and needs many prompts and reminders to complete hygiene routines. Additionally, confidential interviews revealed that due to C1's behavioral needs and safety concerns, hygiene routines were not always prioritized. Based on confidential interviews and record review staff did not ensure minor's hygiene care needs were met may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report and LIC 811 was provided to facility designee.

Investigation Findings:
13On June 10, 2025, at 9: AM, Licensing Program Analyst (LPA) Guadalupe Munoz met with facility representative, Ethan Ali, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 12/19/24 at 10:00 am no deficiencies were observed. LPA interviewed three staff (S1-3) and two clients (C1,C2). During the investigation, the following documents were reviewed: LIC 500 and Staff Schedule, client roster, Needs and Services Plan for Clients, Special Incident Report, Medication Log, C1's JV-220 court document, and C1's 1: Log. On 12/13/24, Community Care Licensing (CCL) received allegations that facility did not meet the medical needs of minor in care and that lack of supervision of minors in care led to inappropriate sexual contact. Specifically, it was reported that C1's medication was not given to C1 as prescribed by doctor and that a resident "inappropriately touched the child while at the STRTP". SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 06/10/2025

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: Ethan Ali


raw_content:
Narrative:
interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff do not treat minors with respect which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Ethan Alli. A copy of this report will be placed in the facility file.

Investigation Findings:
13On June 17, 2025, at 9:50 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Ethan Alli, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on March 24, 2025, at 3:00 pm, and no deficiencies were observed. LPA interviewed one Client (C2), four Staff (S1-4), and LPA was unable to interview one Staff (S5), despite multiple attempts to contact them, and Licensing Program Manager (LPM) Ann Valenzuela interviewed one Client (C1). LPA reviewed Law Enforcement Incident Reports and facility documents during the investigation. On March 17, 2025, Community Care Licensing (CCL) received an allegation that staff do not treat minors with respect. It was reported that C1 and C2 were walking away from the facility, staff were following them, and when Law Enforcement responded to the area, staff members were laughing, clapping, and told the clients to "run into the street." Confidential interviews revealed conflicting statements. Confidential UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 06/17/2025

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


raw_content:
Narrative:
them up. Based on confidential interviews, the allegation that S1, S2, and S7 poured water on clients face is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the Interim Licensing Standards STRTP 87072(c)(1) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Ethan Alli. A copy of this report will be placed in the facility file.

Investigation Findings:
13On June 17, 2025, at 10:15 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Ethan Alli, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on March 24, 2025, at 1:30 pm. No deficiencies were observed. LPA interviewed one Client (C1), six Staff (S2-5, S8-9), and LPA was unable to interview three Staff (S1, S6-7), despite multiple attempts to contact them. LPA reviewed the facility documents. On March 18, 2025, Community Care Licensing (CCL) received an allegation that S1 poured water on C1's face to wake them up. Confidential interviews indicated that S1, S2, and S7 have used water to flick on C1's face in the morning to help wake up C1. Confidential interviews indicated that staff members used a cup of water and took water on their fingertips and flicked the water on C1's face while C1 was in their bed. The investigation could not determine if there are other staff members that also used water on C1's face to wake SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 06/17/2025

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


raw_content:
Narrative:
**Continued from LIC9099** Confidential interviews revealed that in the attempt to restrain C1, C1 indeed fell onto the ground. Confidential interviews revealed that S1 would yell at C1 to behave. Based on confidential interviews, the allegations that staff (S6) mishandled a minor (C1) while in care and staff (S1) does not ensure dignity to minor (C1) in care are substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of Interim Licensing Standards for Short Term Residential Therapeutic Programs 87072(c)(1) Personal Rights and 87072(c)(15) Personal Rights. Please refer to LIC 9099D page. An exit interview was conducted, and appeal rights explained. A copy of this report, Confidential Names List LIC 811, and appeal rights were provided to Administrator, Ethan Alli. A copy of this report will be placed in the facility file. **Continued from LIC Unsubstantiated** Confidential interviews revealed conflicting statements in which some witnesses saw C1 push themselves off off a couch, and others didn't see how C1 fell, but they did offer medical support which C1 refused care. Confidential interviews revealed conflicting statements in which staff did not take away any phone from C1, nor did they deny C1 access to a phone. S5 remembers helping C1 with the 911 phone call by helping her remember the address of the facility. Based on confidential interviews, the allegation that staff caused injuries to a minor while in care and staff denied a minor access to a telephone may have occurred, however, is not supported or proven by evidence. Therefore, the two allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report was provided to Administrator Ethan Alli.

Investigation Findings:
13On 08/07/2025 at 1:10pm, Licensing Program Analysts (LPA) Gilbert Marquez and Sarah Lo met with South Coast Children's Society - Caladium Administrator Ethan Alli to deliver the findings for the above-stated allegations. On 05/28/2025, LPA and LPM inspected the facility, and no immediate health and safety hazards were observed. The investigation included interviews with five staff (S1, S2, S5, S6, S7, see confidential names list LIC811), one of one client (C1), and a County Social Worker (CSW). In addition, the following documents were reviewed: staff files, C1's file, restraint log, and a Special Incident Report (SIR). On 05/20/ Community Care Licensing (CCL) received a complaint alleging that staff mishandled a minor while in care and staff does not ensure dignity to minor in care. Specifically, it was reported that C1 was attempting to jump out of a first-floor window to escape and run away, staff pealed C1 off the windowsill and pushed C1. Furthermore, it was reported that S1 did bad things and hurt C1. Confidential interviews revealed that S6 did not use approved CPI restraint techniques to support C1 during her attempt to leave the facility through a window; S6 conducted a one person restrain from behind. **Continued on LIC9099C** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gilbert Marquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 08/07/2025

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: Ethan Alli, Administrator


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

Investigation Findings:
13On September 12,2025, at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Ethan Alli, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on April 4, 2025, at 11:00 am, and no deficiencies were observed. LPA interviewed one Client (C2), three Staff (S1-3), and LPA attempted to interview C1 and C1 declined to be interviewed . LPA reviewed Staff Roster and Employee File for S1. On April 2, 2025, at 11:00 am, Community Care Licensing (CCL) received an allegation that staff hit a minor in care. It was reported that sometime between October 2021 and December 2022 when C1 and C2 were placed at facility, S1 hit C1. Confidential interviews revealed conflicting statements regarding the allegation that staff hit minor in care. Confidential interviews did not corroborate the allegation with a preponderance of evidence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 09/12/2025

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


raw_content:
Narrative:
In addition, records reviewed, and confidential interviews confirmed that facility did not follow 1:1 supervision protocol therefore it was confirmed that the Facility did not provide the level of supervision needed to maintain the safety of C1 and other residents. Based on confidential interviews, the preponderance of evidence standard has been met and the allegation that facility staff do not provide adequate supervision to minors is substantiated. The Facility is being cited for violation of the Interim Licensing Standards Version 5, Article 06. 80078(a) Responsibility for Providing Care and Supervision. The facility has been assessed Civil Penalties for repeat violation of this regulation within the past twelve (12) months. An exit interview was conducted, appeal rights were explained, and a copy of this report and Confidential Names List (LIC 811) dated 10/15/25 were provided to facility designee.

Investigation Findings:
13On October 15, 2025, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz met with facility representative, Ethan Ali, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on 04/04/25 at 10: AM with no deficiencies being observed. LPA interviewed four staff (S1-4) and one client (C1). During the investigation, the following documents were reviewed: Facility files and C1's file. On 04/02/25, Community Care Licensing (CCL) received an allegation that staff do not provide adequate supervision to minors. Specifically, it was reported that the Facility does not do enough to stop C1 from leaving the Facility, nor do they do enough to find C1 once C1 elopes. Confidential interviews confirmed that due to C1's highly unsafe behaviors it was determined that C1 would have a 1:1 staff assigned to them and when C1's behavior escalated, supervision needed to increase from one staff to two staff assigned to C1. ***CONTINUED ON 9099C*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 10/15/2025

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

met_with: Ethan Ali and Breanna Tucker


summary: Facility Evaluation

raw_content:
Narrative:
On June 14, 2021, at 10:02AM Licensing Program Analysts (LPA) Adrian Mendez, and Jesus Cervantes, conducted an unannounced Post Licesning/Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA's were met at the facility by Facility Manager Kristen Reindel, and Program Director Rich Boyer. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the medication closet located at the end of the hallway upstairs. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Four bedrooms contain one twin bed, and one bedroom contained two twin beds. The facility has three bathrooms. The water temperature in one of the client bathrooms with the sink was tested at 10:21am and registered at 110.3 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Rich Boyer is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs two Clinical Support Staff, three facility managers and 7 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in April 2021. Program Director has stated that National Accreditation through COA is currently being processed. The Accreditation audit began on 05/26/2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. Two facility staff were interviewed during the inspection. No clients were present at the time of the inspection. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Program Director Rich Boyer.

met_with: Rich Boyer


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021, at 3:26PM Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced annual continuation inspection from June 15, 2021. LPA met with Facility Manager Mallory Mandell. Employee files were not located at the facility and required employee files to be reviewed at Southcoast-Santa Cruz located at Santa Cruz Circle, CA 92626. Five personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site in the Human Resource office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were noted during time of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem, conducted a case management inspection on 5/26/2022 at 9:31AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 10 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 26th, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Sethany Yem observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to the Facility Administrator Omar Gomez. Present in the discussion was Program Director Staci Tornquist and Administrator for San Rafael Facility Joseph Hancock.

met_with: Administrator Omar Gomez


summary: Facility Evaluation

raw_content:
Narrative:
On June 20, 2023 at 10: AM, Licensing Program Analyst (LPA), Sarah Lo, arrived at South Coast Children's Society - Caladium Short-Term Residential Therapeutic Program (STRTP). LPA was greeted and granted access by Administrator/Program Supervisor (PS), Ethan Alli. The purpose of the visit is to conduct an annual inspection of the facility. There were three staffs and two clients present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection. At 10: AM, Administrator/Program Supervisor led the physical inspection of the facility. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the medication closet located next to the bathroom upstairs. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and two bedroom contained two twin beds. The facility has three bathrooms but only two of the three bathrooms are for client use only. The water temperature in the client bathrooms with the sink was tested at 10: AM and registered at 118.7 and 119.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Continued on LIC 809-C Per Administrator/Program Supervisor, no firearms or weapons are allowed in the facility. Administrator/Program Supervisor is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. The facility employs four Clinical Support Staff, two facility managers and 3 full time direct care staffs and 5 regular part-time/on-call staffs that are used in accordance with regulatory requirements. Licensee has obtained National Accreditation through COA and the Accreditation is valid through September 30, 2025. The facility annual licensing fees are paid to current. Licensee has mental health approval and good until February 16, 2024. LPA reviewed four out of four client files and each file met the minimum requirement per the Interim Licensing Standards (ILS). All client records reviewed had the required documents including admission agreements, personal rights, medical history, immunization records, medical consent form, and an initial or updated needs and services plan on file. LPA reviewed five staff files and each file met the minimum requirement per the Interim Licensing Standards (ILS). All personnel records reviewed have the verification of Department of Justice, Federal Bureau of Investigations, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging confidentiality and mandated child abuse reporting requirements. All personnel records reviewed met the required education and experience requirement. All personnel records reviewed had a completed physical exam on file. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints, LPA will return to the facility to conduct a continuation of the annual inspection and interviewing of staff/client. No deficiencies were found. An exit interview was conducted and a copy of this report was provided to the Administrator/Program Supervisor, Ethan Alli.

met_with: Ethan Alli, Administrator/Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2023 at 10: AM Licensing Program Analyst (LPA), Sarah Lo, conducted an unannounced annual continuation inspection from June 20, 2023. LPA met with Ethan Alli, Administrator/Program Supervisor. On June 20, 2023, LPA completed the Physical Plant, Staffing Records and Client Records. On June 23, 2023, LPA continued on to complete the following inspection: Operational Requirement, Disaster Preparedness, Emergency Intervention Plan, Core/Therapeutic Services and Staff/Client Interviews. LPA completed two client interviews and two staff interviews during this visit. No deficiencies were noted during time of inspection. An exit interview was conducted. A copy of this report and LIC 811 given to Administrator/Program Supervisor, Ethan Alli.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas conducted a case management inspection August 2, 2023, at 10:45am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 3 out of Direct Care Staff and 1 out of 3 youth were interviewed (See the Confidential Names List, LIC 811, dated August 2, 2023). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth treatment plans, quarterly assessments, and safety intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff and youth indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Rosas observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance with their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator/Program Supervisor, Ethan Alli.

met_with: Ethan Alli, Program Supervisor/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Joon Choi and Guadalupe Munoz on 01/30/2024 at 08: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPAs Choi and Munoz met with Program Supervisor Ethan Alli and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPAs reviewed 3 of child's records and 3 of staff personnel files on site at the facility. LPAs reviewed 3 of child's psychotropic medications and medication records. LPAs interviewed 3 of staff on site to discuss the facilities policies and procedures of operation. LPAs will interview 2 children currently prescribed psychotropic medication, at their schools, after the facility visit.. LPA provided a copy of this licensing report to Ethan Alli, Program Supervisor. No deficiencies are being cited at this time, but the facility was provided with a Technical Assistance (TA) note. LPAs conducted exit interview with Program Supervisor Ethan Alli and provided a copy of this report and the TA.

met_with: Ethan Alli, Program Supervisor


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On August 6, 2024 at 10: AM, Licensing Program Analyst (LPA), Guadalupe Munoz, arrived at South Coast Children's Society - Caladium Short-Term Residential Therapeutic Program (STRTP). LPA was greeted and granted access by Facility Manager, Victor Colli. The purpose of the visit is to conduct an annual inspection of the facility. Administrator/Program Supervisor, Ethan Alli led LPA on the physical inspection of the facility. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the medication closet located next to the bathroom upstairs. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and two bedroom contained two twin beds. The facility has three bathrooms but only two of the three bathrooms are for client use only. The water temperature in the client bathrooms with the sink was tested at 116.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per Administrator/Program Supervisor, no firearms or weapons are allowed in the facility. Licensee has obtained National Accreditation through COA and the Accreditation is valid through September 30, 2025. The facility annual licensing fees are paid to current. Licensee has current mental health approval. LPA reviewed six out of six client files and each file met the minimum requirement per the Interim Licensing Standards (ILS). All client records reviewed had the required documents including admission agreements, personal rights, medical history, immunization records, medical consent form, and an initial or updated needs and services plan on file. LPA reviewed five staff files and each file met the minimum requirement per the Interim Licensing Standards (ILS). All personnel records reviewed have the verification of Department of Justice, Federal Bureau of Investigations, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging confidentiality and mandated child abuse reporting requirements. All personnel records reviewed met the required education and experience requirement. All personnel records reviewed had a completed physical exam on file. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints, LPA will return to the facility to conduct a continuation of the annual inspection and interviewing of staff/client. Facility is being cited for ILS v Section 87065 (d)(1) Personnel Requirements and ILS v Section 87095.61(g) Documentation and Reporting Requirements. An exit interview was conducted and a copy of this report was provided to the Administrator/Program Supervisor, Ethan Alli.

Deficiencies:
87095.61(g): Documentation and Reporting Requirements

(g) The licensee must maintain a monthly log of each use of manual restraints. The log must include


summary: Facility Evaluation

raw_content:
Narrative:
On August 13, 2024, at 10: AM Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced annual continuation inspection from August 6,2024. LPA met with Facility Manager, Victor Colli and toured the facility. The purpose of the visit is to conduct client and staff interviews to complete the annual inspection that started on 8/6/24. LPA conducted two staff interviews. LPA conducted one client interview and two clients declined. . No deficiencies were noted during time of inspection. An exit interview was conducted and a copy of this report and LIC 811 dated 8/13/24 was provided to Facility Manager.

met_with: Victor Colli


summary: Facility Evaluation

raw_content:
Narrative:
On this date at 12:05 pm, Licensing Program Analyst (LPA) Licensing Program Analyst (LPA) Charmaine Linley made an unannounced visit at above facility. LPA met with Victor Colli, Facility Manager. LPA toured the facility and no deficiencies were observed. The purpose of the visit was to conduct a collateral interview for a complaint that does not involve this facility. LPA attempted to interview one client (C1) and client declined to interview. An exit interview was conducted with Victor Colli. Due to printer malfunction a copy of this report will be emailed to the Facility Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/16/25, at 9: AM, Licensing Program Analyst (LPA) Gilbert Marquez met with Administrator Ethan Alli, for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve six ambulatory children ages 12-17 years-old and non minor dependents. The current census is six children. The Facility is current with their licensing fees. The Facility is a double story dwelling. A physical plant inspection was completed with an Direct Care Staff, Anna Rodriguez and included the following checks: kitchen, medication room, dining room, living room, den, two staff offices, and outdoor living space. Two bedrooms contain one twin bed, and two bedrooms contained two twin beds. The facility has three bathrooms but only two of the three bathrooms are for client use only. All beds were observed with appropriate bedding and mattress in good repair. Bedrooms contained adequate drawers and closet space. No bedroom occupied more than two clients and not used for other purposes. The water temperature was tested in bathroom one which measured 115 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to everyone and had all required supplies. All required forms are posted including Grievance Procedures, Personal Rights, Foster Care Ombudsman poster, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in the medication room. **Continued on LIC809C** **Continued from LIC809** Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. All client files are stored and maintained on a secure internet database. LPA reviewed five client files (C1 - C6) to ensure clients had all required documents per Title 22. Client files had education records, physical examinations, Needs and Services plans, and case manager notes. LPA reviewed five client medication records. All staff records are stored via a secured records portal. LPA reviewed five staff files (S1 - S5) to ensure staff had all required documents per Title 22 regulations. Per a review of Guardian, all staff have a criminal record clearance. All staff files also had applications, job descriptions, resumes, physical health screenings, drivers licenses, and training certificates. LPA conducted three staff interviews (S1, S2, and S3 - See LIC Confidential Names List) and one client interview (C3). The other clients declined to be interviewed. Per facility staff, no firearms or weapons are allowed in the facility. One type B deficiency is being given per California Code of Regulations Title 22, Division 6, Client Records, Section 80069(c)(1) The medical assessment shall include the following: The results of an examination for communicable tuberculosis and other contagious/infectious diseases. This requirement is not met as evidenced by: based on interview and record review, the licensee did not comply with the section cited above in three out of six clients (C1, C2, C5) which poses a potential health and safety risk to persons in care. An exit interview was conducted, a plan of correction was created, and appeal rights were discussed. A copy of this report, LIC811, and appeal rights were provided to Ethan, Administrator. A copy of this report will be placed in the facility file