raw_content:
Narrative:
LPA Sanchez P. was able to conduct an interview with NMD1 who confirmed receiving requested hygiene products and has been reimbursed for purchased hygiene items bought with her own funds. LPA Sanchez P. also conducted a confidential interview with a collateral contact who reported not having any concerns regarding the complaint allegations. Lastly, confidential interviews conducted further revealed that there is no evidence to determine that staff did not treat minor with respect. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was completed and copy of the report and appeal rights were discussed and provided to Daisy Delgado, Administrator.

Investigation Findings:
13On October 17, 2025, at 1:10pm Licensing Program Analyst (LPA), Emelyn Sanchez P. made an unannounced visit to the above facility to conclude the complaint investigation and to deliver the findings on the above allegations. LPA Sanchez P. met with Daisy Delgado, Administrator. During the investigation, LPA Sanchez P. conducted interviews with all available parties and gathered pertinent information in reference to the complaint allegations. LPA Sanchez P. reviewed the LIC 500- Personnel Report, Child and Family Team Meeting notes, Needs & Services Plans, and hygiene supply forms for NMD 1. Based on confidential interviews conducted with staff and reviewed documentary evidence regarding the allegation of staff are not providing youth with basic hygiene items it was reported that residents in care receive and fill out a supply order monthly or as needed. Staff further reported that residents can request other hygiene items not identified on the list. Report Cont. on LIC 9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Emelyn Sanchez Peralta LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 10/17/2025

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

met_with: Daisy Delgado, Administrator


state: CA

facility_name: ST. ANNE'S MATERNITY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On February 24, 2026, at 12: PM, Licensing Program Analysts (LPAs) Aimee Moratalla and Cheri Wilkerson made an unannounced visit to St. Anne's Family Services for the purpose of an Annual/Random Inspection. LPA met Daisy Delgado, Facility Administrator and Elizabeth Dennin, Quality Manager who granted access to the facility and a tour of the facility was conducted. This facility is licensed to provide care and supervision to 16 ambulatory residents ages 11-17. The license includes a mother/child component approved for infants ages 0 through 3 and the facility is approved to serve Non-Minor Dependents. The current census is 12 youths and 7 babies. Currently residing in the facility are DCFS, probation, and dual clients. The STRTP facility is located in the main building of the campus with 17 bedrooms, located on the first and second floors, with private bathroom in each room. Bedrooms: Rooms are equipped with 1 full size beds, crib/toddler bed, adequate drawers and closet space, desk with chair and private bathrooms in each room. There is a laundry room in each floor. The third floor is dedicated for staff offices, a conference room. Recreation rooms in each circle, equipped with television and couches. LPA observed car seats, strollers baby toys, and highchairs. A round table with adequate seating, computers, board games, reading books, arts and crafts. Page 1 of A locked medication room, a recreation/activity room, cafeteria supplied with sufficient perishables and non-perishables with a posted menu. LPA observed lockers to store clients' personal belongings. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris and observable hazards. Adequate indoor and outdoor activity space and materials were observed. There is a hardwired alarm system and copy of the fire clearance will be emailed later. Fire extinguishers observed to be all properly charged and serviced. All required forms are posted. Medications are locked and centrally stored in the health services department. Licensee has provisions for contraceptives to be held by clients or held by facility in the health services department unit located on the 2nd floor. Facility has cameras in common areas of the facility. The hot water measured at 113.5 degrees and is within the acceptable temperature range of 105 and 120 degrees. Administrator is present at the facility for a minimum of 40 hours a week. An exit Interview was conducted, and a copy of this report will be emailed Daisy Delgado.

report_type: Facility Evaluation

visit_type: Annual

met_with: Facility Administrator, Daisy Delgado


summary: Facility Evaluation

raw_content:
Narrative:
On March 18, 2026, at 10: AM, Licensing Program Analyst (LPA) Aimee Moratalla and Licensing Program Manager (LPM) made an unannounced visit to the above facility for the purpose of conducting a Case Management - Annual Continuation inspection from the initial visit conducted on 02/24/2026.

visit_type: Case Management

met_with: Assistant Program Administrator, Mitzuky Orellana


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 3/18/2026, Licensing Program Analyst (LPA) Aimee Moratalla conducted an unannounced Case Management visit while on-site reviewing facility files. During a walkthrough of the facility, the following was observed: · In the kitchen, LPA observed multiple food items that were expired and additional food items that were not labeled, including perishable items. · In a client bedroom, LPA observed food scattered throughout the room, creating unsanitary conditions. Additionally, there were no trash cans with lids present in the bedroom. Based on LPA observations and staff statements, the facility failed to maintain a clean, safe, and sanitary environment and failed to ensure appropriate care and supervision of clients in care. LPA observed expired and unlabeled food in the kitchen, as well as unsanitary conditions in a client bedroom, including food scattered throughout the room and lack of appropriate trash receptacles. Staff indicated the client was AWOL The licensee was advised that regardless of a client's AWOL status, the facility remains responsible for always maintaining a safe and sanitary environment and ensuring appropriate care and supervision. Deficiencies were cited on this date. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to Mitzuky Orellana, Assistant Program Administrator.

Deficiencies:
80087(a): Licensee shall clean and sanitize the client bedroom and maintain the facility in a clean and sanitary condition. Licensee shall provide trash cans with tight-fitting lids in client bedrooms and submit receipts and photos verifying compliance.

title:
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7Section 80087(a) - Buildings and Grounds
The facility shall be clean, safe, sanitary, and in good repair at all times.
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7Section 80087(a) - Buildings and Grounds


facility_name: ST. VINCENT'S  SCHOOL FOR BOYS

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 05/19/ Licensing Program Analyst (LPA) Cheyenne McCambridge conducted a follow-up complaint investigation at the facility and met with Administrator Ann Anderson. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation LPA McCambridge conducted staff and client interviews. During an interview with S1, S1 stated C1 returned to campus after an AWOL with a bebe gun. S1 immediately called the Sheriffs after becoming aware of the situation. The sheriffs removed the gun and bebes and issued a ciation to C1. Other staff and clients interviewed provided similar information. Although, C1 did bring a bebe gun back to campus staff acted fast and followed approriate steps to ensure other client and staff safety. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a minor had access to a bebe gun while in care; therefore, the above allegation is unsubstantiated. Appeal Rights were provided and discussed with staff and no deficiencies were cited. Exit interview was conducted and a copy of the report was left with the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

report_type: Complaint Investigation

met_with: Ann Anderson

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On 05/21/ Licensing Program Analyst (LPA) Cheyenne McCambridge conducted a follow-up complaint investigation at the facility and met with Administrator Ann Anderson. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation LPA McCambridge conducted staff and client interviews and reviewed documentation. During an interview with C1, C1 stated that the incident did occur, but C1 could not provide any details on the incident. C1 could not provide witnesses, staff names, or the events leading up to or during the incident. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that staff inappropriately kicked a minor in care; therefore, the above allegation is unsubstantiated. Appeal Rights were provided and discussed with staff and no deficiencies were cited. Exit interview was conducted and a copy of the report was left with the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On 6/29/ Licensing Program Analyst (LPA) David Hiett conducted a follow-up complaint inspection with the facility and met with Administrator Ann Anderson. The purpose of the inspection was to deliver the finding for the above complaint allegation. At this time no deficiencies were observed. Interviews with staff indicated that the were familiar with restraint procedures in accordance with their training and that injuries due to restraints were unlikely. Interviews with clients did not corroborate any of the claims made by the client. During the course of investigating this allegation, interviews were conducted with staff and clients and records were reviewed. This department has investigated the complaints alleging that staff encouraged facility clients to fight and that staff member inappropriately physically handled facility client. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation did or did not occur; therefore, the above allegation is unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13ON 6/29/ Licensing Program Analyst (LPA) David Hiett conducted a follow-up complaint inspection with the facility and met with Administrator Ann Anderson. The purpose of the inspection was to deliver the finding for the above complaint allegation. At this time no deficiencies were observed. During the course of investigating this allegation, interviews were conducted with clients and records were reviewed. C2 no longer resides at the facility and having turned 18 is no longer in the foster care system and LPA was unable to contact him. C1 appeared to be truthful and credible, however he admits to having only vague recollections of the incidents due to his medications. Bed check logs did not yield any indicating that C2 was outside of his room during those times. Based on this conflicting information, the allegation cannot be confirmed. This department has investigated the complaint alleging that lack of supervision resulting in inappropriate touching between minors while in care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation did or did not occur; therefore, the above allegation is unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) David Hiett met with Administrator Ann Anderson regarding a complaint investigation at the Short Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Hiett inspected the facility, interviewed 3 youth, 3 staff and reviewed documentation. LPA confirmed through interviews with staff and clients and record reviews that the client's injury was caused by the manual restraint. Based on the information obtained, there is a preponderance of the evidence to prove that staff violated the client's personal rights by causing injury due to a manual restraint. Therefore, the above allegation is substantiated. ILS deficiencies were cited regarding the restraint and an Advisory Note was issued regarding door removal. Appeal Rights were provided and discussed with the facility. An exit interview was conducted, and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett 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 21-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, NEOTOMAS AVENUE, STE. Santa Rosa, CA Facility Name: St. VINCENT'S SCHOOL FOR BOYSFACILITY NUMBER: 216801396

met_with: Administrator Ann Anderson


raw_content:
Investigation Findings:
13During the course of the investigation, LPA Hiett inspected the facility, interviewed 3 youth and 3 staff, and reviewed documentation. LPA confirmed through interviews with staff and clients and record reviews failed to corroborate that the client has been bullied, assaulted by other minors, yell at minor or failed to intervene in physical altercations. Injuries observed on client were accidental in nature which is supported by statments made by client and record reviews. Client's current authorized representative is the Social Worker and based on record reviews has been properly notified of all incidents. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was sent to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) David Hiett made an unannounced complaint investigation at the facility and met with William Webster, Director of CQI. The purpose of the inspection was to deliver findings on the above allegation. During the course of the investigation LPA Hiett interviewed 4 clients and 2 staff, and reviewed records. The records and the interviews indicated that a staff member did choke the minor through the improper use of a manual restraint. Based on the information obtained, there is a preponderance of the evidence to prove that the facility did not properly complete comply with the client's Personal Rights. Therefore, the above allegation is substantiated. Title 22 deficiencies were cited, and Appeal Rights were provided and discussed with the facility. An exit interview was conducted, and a copy of the report was left withWilliam Webster, Director of CQI. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett 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 21-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, NEOTOMAS AVENUE, STE. Santa Rosa, CA Facility Name: St. VINCENT'S SCHOOL FOR BOYSFACILITY NUMBER: 216801396

met_with: William Webster, Director of CQI

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) David Hiett made an unannounced complaint investigation visit at the facility and met with Assitant Program Director Maria Ramos The purpose of the inspection was to deliver findings regarding the above allegation. Investigator Jorge Martinez conducted the investigation. During the course of the investigation Inv. Martinez conducted confidential interviews and reviewed relevant reports. Investigator Martinez was unable to determine if the minor was sexually abused by other minor while in care. There is a lack of clear evidence to make a determination as to whether a regulatory violation did occur. This department has investigated the allegations and although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that minor was sexually abused by other minor; therefore, the above allegation is Unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett 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: Maria Ramos


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) David Hiett met with Assistant Program Director Maria Ramos regarding a complaint investigation at the Short Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation, LPA Hiett inspected the facility,conducted confidential interviews and reviewed documentation. LPA Hiett confirmed through interviews with staff and clients and record reviews that minor was sexually and phyiscally assaulted by another minor while in care. Based on the information obtained, there is a preponderance of the evidence to prove that minor was sexually and phyiscally assaulted by another minor while in care. Therefore, the above allegation is substantiated. ILS deficiencies were cited. Appeal Rights were provided and discussed with the facility. An exit interview was conducted, and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: David Hiett 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 21-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, NEOTOMAS AVENUE, STE. Santa Rosa, CA Facility Name: St. VINCENT'S SCHOOL FOR BOYSFACILITY NUMBER: 216801396


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) David Hiett made an unannounced complaint investigation visit at the facility and met with Assitant Program Dirctor Maria Ramos The purpose of the inspection was to deliver findings regarding the above allegation. Investigator Jorge Martinez conducted the investigation. During the course of the investigation Inv. Martinez conducted confidential interviews and reviewed relevant reports. Investigator Martinez was unable to determine if there was any lack of supervision resulting in sexual abuse of a minor. There is a lack of clear evidence to make a determination as to whether a regulatory violation did occur. This department has investigated the allegations and although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that minor was sexually abused by other minor; therefore, the above allegation is Unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: David Hiett LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Administrator Maria Ramos regarding a complaint investigation at the facility. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA McCambridge interviewed 4 youth and 5 staff, and reviewed documentation. During confidential interviews staff stated that they have not seen or heard about clients being handled in a rough manner. With the victim not wanting to be interviewed LPA is unable to corroborate youth's allegation. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was sent to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Administrator Maria Ramos regarding a complaint investigation at the facility. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA McCambridge conducted confidential interviews, and reviewed documentation. During confidential interviews staff stated that they have not seen or heard about clients being handled in a rough manner. With the victim not wanting to be interviewed LPA is unable to corroborate youth's allegation. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was sent to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Maria Ramos regarding a complaint investigation at the facility (now closed). The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli and Investigator Balarie conducted confidential interviews, and reviewed documentation. During confidential interviews there was no indication the allegation occurred, nor was there any record of the incident in reports received. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was sent to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with current Administrator Maria Ramos and current Program Director Justin Bayne regarding a complaint investigation at the facility (now closed). The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli and Investigator Gonzalez conducted confidential interviews, and reviewed documentation. During confidential interviews there was no indication the allegation occurred, nor was there any record of the incident in reports received. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was sent to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Justin Bayne and Maria Ramos


summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joel Segura on 05/05/2021 at 09:00am. This inspection was conducted via Microsoft teams due to COVID19 restrictions on conducting on site inspections at licensed facilities. LPA Segura sent Director of Continuous Quality Improvement Bill Webster and Administrator Ann Anderson a Document Request checklist on 04/14/2021. LPA received client documents via email on 04/27/2021. The facility has 37 clients in placement at this time. LPA requested to review 10 files of children who are taking psychotropic medications. On todays date LPA Segura interviewed 3 staff at 10am through 10:45am facilitated by Bill Webster. At approximately 9am - 10am LPA Segura initiated a medication count with the facility nurse Kathi Buada via facetime. Kathi and LPA resumed the medication count at 1pm and went through approximately 4pm which included a tour of the individual homes. No deficiencies were observed during this tele-inspection. Further time is needed to complete this inspection. LPA will arrange to deliver inspection findings at a later time. LPA Segura provided this report to the administrator and director of continuous quality improvement via email with a read receipt as acknowledgement the report was received.

met_with: Bill Webster/Kathi Buada


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On10/19/2021, Licensing Program Analyst (LPA) David Hiett conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required visit. LPA Hiett met with Administrator Ann Anderson and inspected the facility, inside and out. Currently 3 of 4 houses are in use (Hanna, McKenna, Riordan). All homes are clean, safe, sanitary, and in good repair. All passageways are unobstructed. There are no bodies of water. No room commonly used for other purposes is used as a bedroom. All bedrooms have adequate closet and drawer space. The homes are maintained at a comfortable temperature. Sharps are kept locked in the kitchen cabinets and toxins are kept locked in cabinets in the kitchen. Medications are kept locked in the staff office. There are carbon monoxide and smoke detectors throughout the facility. There were operable fire extinguishers in the facility. There are complete first-aid kits located in the facility. Applicant understands that the hot water temperature must be maintained within the regulation range of 105-120 degrees. There are no firearms on the property. All required postings are present. 9 staff files and 9 client files were reviewed. 5 staff and 5 clients were interviewed. The Short-Term Residential Therapeutic Program is licensed to serve 67 boys ages 6-17. There are currently 28 residents. The inspection was continued during the following days: 10/20/2021 10/22/2021 10/26/2021 10/27/2021 10/29/2021

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include
80026(h): Safeguards for Cash Resources, Personal Property, and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Hiett conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Administrator Ann Anderson.


summary: Facility Evaluation

narrative: Licensing Program Analyst (LPA) David Hiett conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Administrator Ann Anderson.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Hiett conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Director of Clinical Services Sarah Burton. The following violations were cited: Disaster Preparedness - Technical Assistance: HSC 1565(c) (c) A facility shall conduct a drill at least quarterly for each shift. [and] shall vary from quarter to quarter...Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. Emergency Intervention Plan - Technical Assistance: ILS 87095.65(b)(7) (b) The facility's policies and procedures concerning when and how to involve law enforcement in response to an incident involving a child residing in the facility. Client Records - Technical Violation: ILS 87026(c) (c) The licensee shall ensure that a child's cash resources are not taken in the form of fines. Emergency Intervention Plan - Technical Assistance: ILS 87095.65(b)(5) (b) The emergency intervention training curriculum must address the following areas: (5) Techniques for returning the child to the planned activity following completion of the emergency intervention. Emergency Intervention Plan - Type B: 87095.61(f) (f) The licensee must maintain a monthly log of each use of manual restraints. Staffing Records - Type B: ILS 87066(b)(4) (1) (b) The licensee shall maintain the following personnel records: (4) Documentation of the completion by each direct care staff person and facility manager of the training specified in Sections 87065.1(a) through (d) inclusive. Staffing Records - Type B: ILS 87065(g)(1)(A)(6) Direct care staff shall meet one of the following qualifications: 6. Previously been employed as a full time staff or served as a volunteer at a group home, short-term residential therapeutic program, or substance abuse treatment program for at least one year. Continued on LIC809-D Client Records - Type B: CCR 80026(h) (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her car A copy of this report was left with the facility.

met_with: Sarah Burton


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Brian Bertoli and Cheyenne McCambridge on the above date. During the inspection, LPA McCambridge inspected the facility inside and out. LPA McCambridge reviewed six staff personnel files on site at the facility. LPA McCambridge reviewed child's psychotropic medications and medication records. LPA McCambridge interviewed six staff on site. LPA Bertoli interviewed 10 children currently taking psychotropic medication at their schools. Client files will be reviewed at a later date. LPA conducted an exit interview with Administrator Ann Anderson. LPA provided the Summary Report to the Administrator upon completion. No deficiencies are being cited at this time.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on the above date beginning at 10:30am. During the inspection, LPA Bertoli met with Administrator Ann Anderson and CQI Director Bill Webster and reviewed children's records. Interviews and Staff file reviews were conducted previously. LPA reviewed 9 children's records on site at the facility from 10:30am to 3:00pm. During the review of children's records, LPA Bertoli observed several children's records did not contain signatures on the Needs and Services Plans (NSP) for either the client or the authorized representatives. This was addressed in prior year inspection and facility has updated signatures from last medication inspection and will send verification to LPA. An Advisory Note was issued and LPA will follow-up with verification. No deficiencies are being cited at this time. An exit interview was conducted with Administrator Anderson and CQI Director Webster, and Appeal Rights were discussed, and a copy of this report was left with the facility.

met_with: Ann Anderson and Bill Webster


summary: Facility Evaluation

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Narrative:
On the above date, LPA Hiett conducted a virtual meeting with facility representatives to discuss a forthcoming application for the facility to transition from an STRTP to a Group Home serving Unaccompanied Children placed by the Office of Refugee Resettlement (ORR) in the Department of Homeland Security. Facility representatives at the meeting were: Lauraleigh Hungerford, Associate Director of Client Services Ellen Hammerle, VP of Client Services, Catholic Charities Bill Webster, Director of Continuous Quality Improvement CCL application procedures for a Group Home including required documents Program Statement elements unique to the population served The role of the Case Manager position required by ORR Anticipated length of stay (6-8 weeks per ORR) Identification of the Authorized Representative Staff training needed for the new population Translator services LPA Hiett asked for information from ORR detailing the program which was provided by Mr. Webster.

met_with: Bill Webster


summary: Facility Evaluation

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Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joel Segura on 05/11/2021 at 2:00pm. This inspection was conducted via Microsoft teams due to COVID19 restrictions on conducting on site inspections at licensed facilities. LPA Segura sent Director of Continuous Quality Improvement Bill Webster and Director of Client Services Sarah Burton and Administrator Ann Anderson a Document Request checklist on 04/14/2021. LPA received client documents via email on 04/27/2021. The facility has 39 clients in placement at this time. LPA requested to review 10 files of children who are taking psychotropic medications. LPA met with Client Services Director Sarah Burton, Director of Continuous Quality Improvement Bill Webster and facility Nurse Kathi Buada. LPA Segura and two student assistants reviewed the child files. Review of the files revealed that the following items were observed to be out of compliance. Below LPA will reference each child file as C1 through C10, see confidential name list LIC 811 dated 05/11/2021. C1-10: Psychotropic Medication Administration Records were missing the number of refills as required by ILS (Interim Licensing Standard) 87070. C1, C3, C No Indication the child is participating or offered to participate in the development of their ANSP (Assessment Needs and Services Plan) as required by ILS 87068. C1 - C Services not identified in the ANSP as required by ILS 87068.2. The ILS requires the facility include the types of services necessary, including core services, supports, physical and mental health, substance abuse services and permanency and transition services. Out of the 10 files reviewed, only the ANSP for C10, detailed the services to be provided to the child. Note the facility did submit evidence all children are receiving services; however, these are not noted in the ANSP. Continued on 809C C1, C2, C3, C4, C5, C6, C7, C8, C9, C Assessment Needs and Services Plan (ANSP) not signed by the child, authorized representative or both. C2, C5, C7, Current court or parental authorization for psychotropic medication not present in the child's file. The facility provided copies of emails sent to the county social workers for their efforts to obtain copies of the court authorization On 05/05/2021 at approximately 9am LPA Segura and facility Nurse Kathi Buada conducted a medication count at the four homes; Mitty, Riordan, Hanna and McKenna. The medication count was conducted via Facetime. The facility uses a pharmacy that bubble packs their medication which made viewing the medication more convenient. LPA conducted the count by counting when the medication was started according to the centrally stored log and counted how many pills should remain on 05/05 when the inspection was conducted. Medication will be referenced as M1, 2, 3... etc (medication will be listed on confidential name list LIC811, dated 05/11/2021). The following was observed during the medication count: Hanna: C1 - · 9:45am medication count was found to be correct. C4 - · 9:30am M1 was found to have extra two pills that could not be accounted for through the PMAR or centrally stored medication log Mitty: C2 - · 1:30pm M2 was found to have 2 extra pills that could not be reconciled from the PMAR (Psychotropic Medication Administration) or centrally stored log. C8 - · Medication count was found to be correct C10 - · 1:15pm M1 count found one extra pill that could not be accounted for in the PMAR or centrally stored log Riordan: C3 - · 8:50am M1 was in a liquid form, unable to conduct a pill count. Other medications count were found to be correct. C9 - · 9am medication count was found to be correct. McKenna: C5 - · Medication count was found to be correct C6 - · M1 was found to have an extra 3 pills. M2 had correct amount of pills remaining; however, facility staff were not documenting pills given to the child on the PMAR, meaning they were not signing when pills were dispensed to the child. C7 - · Medication Count was found to be correct On 05/06/ LPA Segura reviewed 3 staff files and did not observe any deficiencies. Staff interviews were conducted on 05/05/2021 at approximately 10am -11am. Child interviews were conducted on the following dates: 04/28/2021 at 3pm C1, C2, C4, C8, C10 04/29/2021 at 3pm C3, C5, C6, C7 04/30/2021 at 3pm C LPA conducted exit interview with Bill Webster, Sarah Burton and Kathi Buada; appeal rights discussed and provided. LPA provided the summary report via email upon completion. LPA requested the documents be signed by the facility administrator and returned at their earliest convenience. ANSP and medication deficiencies were observed and cited form the California Code of Regulations, Title 22, and Health and Safety codes during the inspection. Refer to 809D for citations issued.

met_with: Bill Webster, Sarah Burton


facility_name: SUCCESS IN RECOVERY

summary: Facility Evaluation

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Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA's) Jessica Rodriguez and Lidia Tinoco at Success in Recovery in Visalia, CA. LPA's met with Administrator Shawnaa Supnet and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. No firearms or weapons are allowed in the facility. Fence surrounding the pool is in compliance. There are no pets at the facility. Facility has cameras in common areas as well as sensors in all client bedrooms. Facility appears to be meeting the terms and conditions of their license. LPA's reviewed client files and conducted staff and client interviews. There were no deficiencies to be cited on this date. A copy of this report was left with Shawnaa Supnet. An annual continuation will be completed at the facility main office.

met_with: Shawnaa Supnet


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analysts (LPA's) Jessica Rodriguez and Lidia Tinoco traveled to the Success in Recovery main office in Visalia and met with Brad Harness, Executive Director for the purpose of continuing the facility annual inspection. LPA's reviewed Staff files. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 19, 2020, a review was conducted on June 18, 2021, and have been in contact with the state, the state report has been finalized and is set to be sent to the agency by October 5, 2021 as verified by an email provided to LPA's. The facility has a county contract through July 2023. Licensee has obtained National Accreditation through CARF valid through April 30, 2023. LPA's discussed with Brad the sensors in the client bedrooms. LPA's discussed staff interviews with Brad and covered areas of concerns which included: staffs knowledge of program statement, trauma informed care including but not limited to how it relates to direct care staff, and steps for reporting physical or sexual abuse. No deficiencies were cited during this inspection, a copy of this report was left with Brad Harness.

met_with: Brad Harness


summary: Facility Evaluation

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Narrative:
On 10/17/2022, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery in Visalia, CA to conduct an announced SB Psychotropic Medication Inspection at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Galvan met with Shawnna Supnet , Administrator and inspected the facility inside and out. At 10: AM LPA inspected the facility inside and out. LPA observed all medication, knives, and disinfectants locked. All medications were stored in a lock container inside a locked cabinet. All required documentation was posted and accessible for both staff and client's review. The facility was clean and in good sanitary conditions. Each client was provided a bed, linens, and storage space in their bedrooms. The facility had 3 days of perishables and 7 days of non-perishable. The facility's refrigerator, freezer, and water temperature were all at a safe range. The front and back outdoor areas where free from dangers and hazards. At 10: AM LPA reviewed 3 client's medications and medication records. At 11: AM LPA reviewed Staff and Client files on site at the facility. At 1: PM LPA interviewed 3 clients currently prescribed psychotropic medication. At 1: PM LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA conducted exit interview with Administrator, Shawnaa Supnet at 2: PM. No deficiencies were observed and cited on today's visit. A copy of this report was left with Shawnaa Supnet at the conclusion of the inspection.

met_with: Shawnna Supnet


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez on July 21, 2023, at 9: A.M. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA Rodriguez met with Administrator, Shawnaa Supnet and inspected the facility inside and out. LPA reviewed 1 of 6 child's records and 2 of 2 staff personnel files on site at the facility. LPA reviewed 1 of 6 child's psychotropic medications and medication records. LPA interviewed 2 of 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of 1 children currently prescribed psychotropic medication. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator, Shawnaa Supnet. LPA provided a copy of this licensing report to Administrator, Shawnaa Supnet.


summary: Facility Evaluation

raw_content:
Narrative:
On September 27, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery located in Visalia, California to conduct an unannounced visit and met with Maria Arteaga, Mental Health Technician. The purpose of the visit was to conduct staff and client interviews for the Required/Random Inspection initiated on 9/22/2023. LPA Galvan conducted interview with 4 clients and 2 staff. No deficiencies were issued or observed at this time. A copy of this report was provided to Tiarena Hunt at the conclusion of this inspection.

met_with: Maria Arteaga & Tiarena Hunt


summary: Facility Evaluation

raw_content:
Narrative:
On March 29, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery Main Office located in Visalia, CA, to conduct a Case Management and met with Administrator, Brad Harness and Program Director Elizabeth Reynaga. The purpose of the inspection was to discuss the updates to the Agency's Program Statement. No deficiencies observed or cited during the inspection. A copy of this report was provided to Elizabeth Reynaga at the conclusion of the inspection.

met_with: Elizabeth Reynaga & Brad Harness


summary: Facility Evaluation

raw_content:
Narrative:
On September 27, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery I located in Visalia, CA, and met with Administrator Shawnna Supnet. The purpose of today's inspection is to conduct a 2-year required inspection. Success in Recovery II has a census of (4) children and a capacity for 6 clients. A tour of the facility was conducted, a physical plant inspection was completed and included the following observation: All required forms are posted. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility has an above ground that is enclosed with a locked gate meeting regulatory requirement. All required forms are posted. The temperature of the facility was a comfortable temperature of 75 degrees. All facility smoke detectors are in appropriate working order and all fire extinguishers are properly charged and serviced. The kitchen has a full-size refrigerator and is operating at safe temperature. The facility maintains an adequate supply of perishable and non-perishable foods and the food menu is available for children to view. A supply of emergency food is stored at the facility. Knives, sharps, medications, chemicals, disinfectants, and cleaning solutions are key locked and inaccessible to children in care. LPA observed medications are centrally stored. The dining room is equipped with large table and chairs accommodating of all children in care. There are three bedrooms- for double occupancy, all bedrooms are located on one single level. Bedrooms are accommodating of all required furnishings and storage space. Six individual beds were observed with appropriate clean linens and in good repair. The facility has 3 bathrooms, 1 is used for children, 1 for Direct Care Staff, and 1 for Mental Health Staff, all are operable. All restrooms are stored with hand soap, toilet paper, and paper towels. The facility water temperature is at a safe temperature range. The First Aid kit is complete with all first aid items. The facility has a staff office and is inaccessible to children. No firearms or weapons are allowed in the facility. Continued on Page 2... Continued from page 1... There are currently Chief Executive Officer, Program Director, Administrator, Social Worker, Clinician, Direct Care Staff, Head of Service. LPA reviewed 4 children and 5 staff files. A review of the background clearances was conducted September 27, 2024, indicates that all facility staff associated to the agency have DOJ, FBI, and child abuse index check clearances. The facility currently holds a Mental Health Program Approval valid through September 19, 2025. The licensee has obtained National Accreditation through The Joint Commission valid through April 30, 2026. LPA will need to continue the inspection to complete review documentation, staff, and children's interviews. There were no deficiencies issued today. A copy of this report was provided to Shawnna Supnet at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On October 4, 2024, Licensing Program Analysts (LPA) Vanessa Galvan and Olivia Medrano traveled to Success in Recovery located in Visalia, California to conduct an unannounced visit and met with Administrator Shawnna Supnet. The purpose of the visit was to complete the 2-year required inspection that was started on 09/27/2024. LPA Galvan conducted interview with 4 clients and 2 staff. LPAs reviewed board meeting minutes, the disaster preparedness plan, vehicle inspections, and conducted staff and client interviews. A technical violation is issued on this date for failure to document each client's bedroom sharing arrangement and compatibility. LPA discussed with the Administrator the staffing requirements for facility managers. A copy of this report and the technical violation was provided to Shawnna Supnet at the conclusion of this inspection.


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Reyna Martinez on July 10, 2025 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Shawnaa Supnet, Administrator and inspected the facility inside and out. LPA reviewed 0 child record and 2 staff personnel files on site at the facility. LPA reviewed 0 child psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA did not interview any children as they did not meet the criteria for review. No deficiencies are being cited at this time. LPA conducted an exit interview with Shawnaa Supnet, Administrator and a copy of this report was left with facility.


summary: Facility Evaluation

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Narrative:
On April 10, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery Short-Term Residential Therapeutic Program in Visalia, CA, to conduct a Case Management and met with Administrator, Shawnna Supnet and Social Worker Joseph Lovett. The purpose of the inspection is to discuss two incident report that was submitted to the department on 04/02/2025 and 04/09/2025. The incident reports disclosed that Client 1 (C1) engaged in sexually inappropriate activities with Client 2 (C2) and Client 3 (C3). (See LIC 811 for confidential names) According to the reports, the activity was consensual among the clients. During the inspection, the LPA conducted confidential interviews and discussed supervision, safety, and bedroom-sharing arrangements as well as compatibility among the roommates/clients. LPA also conducted a physical plant check. The Agency is being cited for the Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Buildings and Grounds. (See LIC 809D) An exit interview was conducted to discuss this report, LIC 811, and appeal rights. A copy of this report, appeal rights, and LIC 811 were provided to Shawnna Supnet at the conclusion of the inspection.

met_with: Shawnna Supnet & Joseph Lovett


summary: Facility Evaluation

raw_content:
Narrative:
On August 17, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery Short-Term Residential Therapeutic Program located in Visalia, CA, and met with Shawnaa Supnet, Administrator. The purpose of this unannounced inspection is to conduct a Case Management regarding a late incident report that the facility submitted to Community Care Licensing. On August 3, 2023, the facility submitted an incident report for an incident that occurred from April 28, 2023. Based on the LPA's investigation and observation, it was determined that the facility has failed to submit an Incident Report within the seven days the incident occurred. The facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements. An exit interview was conducted to discuss this report and appeal rights. A copy of this report and appeal rights were provided to Shawnaa Supnet, at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 28, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery Short-Term Residential Therapeutic Program in Visalia, CA, to conduct a Case Management and met with Administrator, Shawnna Supnet. The purpose of the inspection is to discuss an incident report that was submitted to the department on 11/21/2023 regarding client 1 (C1) being administered incorrect medication by Staff 1 (S1). (See attached LIC 811) On November 20, 2023, at 8:24 pm, C1 was given incorrect medication, C1 was given C1's morning medication by S1 instead of the evening medication, the mistake was realized after C1 swallowed the medication. C1 stated that it would interfere with sleep pattern. S1 called and reported this incident to the Administrator (ADM). ADM made sure that all staff were checking on C1 regularly throughout the night. LPA Galvan reviewed files and conducted interviews. LPA discussed with ADM the concerns of S1 administering incorrect medication, the importance of all staff verifying & confirming the correct medication is being administered and maintaining medication quality assurance. Based on interviews and record review, the Agency is being cited for the Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Health Related Services. An exit interview was conducted to discuss this report and appeal rights. A copy of this report, appeal rights, and LIC 811 were provided to Shawnna Supnet at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery House One Short-Term Residential Therapeutic Program located in Visalia, CA, to conduct an unannounced Case Management and met with Facility Representative Toni Brown. The purpose of the inspection is to discuss an incident report that was submitted to the department on 09/12/2024 regarding a medication error. On 09/11/2024, Staff 1 (S1) failed to administer client 1's (C1) (see LIC 811 for confidential names) evening medication. The medication error was noticed the following morning on 09/12/2024. C1 did not report feeling any changes or side effects due to the missed dosage. Administrator met with S1 and counseled S1 on medication procedures. Based on document review, the Agency is being cited for Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Health Related Services and a civil penalty is being issued. An exit interview was conducted to discuss this report, appeal rights, and LIC 811. A copy of this report, appeal rights, and LIC 811 were provided to Toni Brown at the conclusion of the inspection.

met_with: Toni Brown


raw_content:
Investigation Findings:
13On January 22, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery located in Visalia, CA, to conduct an unannounced inspection and met with Head of Service, Rilee Hopper. The purpose of the inspection is to deliver the findings for the above allegation. The above allegation was referred to Community Care Licensing for an investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on confidential interviews and other information obtained, the Department has made the following determination. Although the allegation may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report and appeal rights were discussed and provided to Rilee Hopper at the conclusion of the inspection via email due to printer error. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/24/2025 and conducted by Evaluator Vanessa Galvan PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:SUCCESS IN RECOVERYFACILITY NUMBER: ADMINISTRATOR:SHAWNAA SUPNETFACILITY TYPE: ADDRESS: W. HOWARD AVETELEPHONE: (559) 635- CITY:VISALIASTATE: CAZIP CODE: CAPACITY:6CENSUS: 4DATE: 01/22/ UNANNOUNCEDTIME BEGAN: 10: AM MET WITH:Rilee HopperTIME COMPLETED:11: AM 9Staff speaks to minors inappropriately Staff had inappropriate interactions with minors Lack of supervision by staff INVESTIGATION FINDINGS: 13On January 22, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery located in Visalia, CA, to conduct an unannounced inspection and met with Head of Service, Rilee Hopper. The purpose of the inspection is to deliver the findings for the above allegations. The Department has investigated the above complaint allegations. During the investigation, LPA conducted confidential interviews and reviewed files. Based on information obtained and confidential interviews it was determined that the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. The agency is being cited for Title 22, Interim Licensing Standards, Article 06., sections Personal Rights(c)(15), Personal Rights (c)(16) and Title 22, Division 6, Chapter 1, Article 06., section Responsibility for Providing Care and Supervision(a). See Attached LIC 9099D for further information. A copy of this report and appeal rights were provided and discussed to Rilee Hopper at the conclusion of the inspection via email due to printer error. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: SUCCESS IN RECOVERYFACILITY NUMBER: 547202542

met_with: Rilee Hopper


summary: Facility Evaluation

raw_content:
Narrative:
On March 20, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery Short-Term Residential Therapeutic Program located in Visalia, CA, and met with Shawnaa Supnet, Administrator. The purpose of this unannounced inspection is to conduct a Case Management regarding an incident not reported to Community Care Licensing (CCL). While conducting a complaint investigation it was determined that a reportable incident was not reported to CCL. The incident took place in the month of June 2025, involving Client 1 and Client 2. The facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements. An exit interview was conducted to discuss this report and appeal rights. A copy of this report, appeal rights, and LIC 811 were provided to Shawnaa Supnet at the conclusion of the inspection.


raw_content:
Investigation Findings:
13On March 20, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery Short-Term Residential Therapeutic Program located in Visalia, CA, and met with Shawnaa Supnet, Administrator. The purpose of the inspection is to deliver the findings for the above allegation. The Department has investigated the above complaint allegation. LPA conducted confidential interviews, reviewed files, and obtained pertinent documentation. Based on confidential interviews, the department found that there was conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation is Unsubstantiated at this time. A copy of this report and appeal rights were discussed and provided to Shawnaa Supnet at the conclusion of the inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/18/2026 and conducted by Evaluator Vanessa Galvan PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:SUCCESS IN RECOVERYFACILITY NUMBER: ADMINISTRATOR:SHAWNAA SUPNETFACILITY TYPE: ADDRESS: W. HOWARD AVETELEPHONE: (559) 635- CITY:VISALIASTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 03/20/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Shawnaa SupnetTIME COMPLETED:01: PM 9Staff did not provide adequate supervision resulting in minor engaging in inappropriate behavior with another minor. INVESTIGATION FINDINGS: 13On March 20, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery Short-Term Residential Therapeutic Program located in Visalia, CA, and met with Shawnaa Supnet, Administrator. The purpose of the inspection was to deliver the findings regarding the above complaint allegation. The Department has investigated the above complaint allegation. LPA conducted confidential interviews, reviewed files, and obtained pertinent documentation. Based on confidential interviews, it was determined that the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The agency is being cited for Title Division 6, Chapter 1, Article 06. Continuing Requirements, Section Responsibility for Providing Care and Supervision 80078 (a). See Attached LIC 9099D for further information. An exit interview was conducted discussing this report and the appeal rights. A copy of this report, appeal rights, and LIC 811 was provided to Shawnaa Supnet at the conclusion of the inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: SUCCESS IN RECOVERYFACILITY NUMBER: 547202542


facility_name: SUCCESS IN RECOVERY II

summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joel Segura on 06/14/2021 at 09:00am. This inspection was conducted via MS Teams and Facetime due to COVID19 restrictions on conducting on site inspections at licensed facilities. LPA Segura sent the Administrator Shawnaa Supnet a Document Request checklist on 06/01/2021. LPA Segura received client and staff documents via email on 06/08/2021. The facility has 5 clients in placement at this time. At the time of this inspection there were only two minor children who are subject to this psychotropic medication inspection. On 06/08/ Student Assistant Stephanie Martinez reviewed Assessment Needs and Services Plan, Psychotropic Medication Administration Record (PMAR), Centrally Stored Medication logs, and JV220/JV223. The review did not result in any deficiencies, the documentation submitted was in compliance with the STRTP (Short Term Residential Therapeutic Program) Interim Licensing Standards. On 06/14/ LPA Segura conducted interviews with the two clients (C1 and C2, See confidential names list LIC 811, dated 06/14/2021) at approximately 9:10am. On 06/14/ LPA conducted SB Psychotropic Medication interviews at approximately 9:45am with three staff , Administrator Shawnaa Supnet, Mental Health Rehabilitation Specialists David Allen Delgado and Maria Artiaga. At approximately 10:30am LPA Segura conducted a facility inspection via Facetime for ease of inspecting the facility. This was facilitated by Shawnaa who walked throughout the home, inside and out. No deficiencies were observed during this inspection. Continued on 809C LPA Segura conducted an exit interview with Shawnna Supnet. Administrator at 11:30am. LPA Provided the Summary Report to Shawnna upon completion via email. LPA requested the administrator to sign and return the report. No deficiencies are being cited at this time. See Technical Assistance LIC 9102 for non psychotropic medication related advisory note.


summary: Facility Evaluation

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Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA's) Lidia Tinoco and Vanessa Galvan traveled to Success in Recovery II in Visalia, CA. LPA's met with Administrator Shawnaa Supnet and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 19, 2021, a review was conducted on June 18, 2021, and have been in contact with the state, the state report has been finalized and is set to be sent to the agency by October 5, 2021 as verified by an email provided to LPA's. The facility has a county contract through July 2023. Licensee has obtained National Accreditation through CARF valid through April 30, 2023. No firearms or weapons are allowed in the facility. Facility has cameras in common areas as well as sensors in all client bedrooms. Facility appears to be meeting the terms and conditions of their license. LPA's reviewed staff and client files and conducted staff and client interviews. LPA's issued two type A Deficiencies which were corrected and cleared during the visit. A copy of this report was left with Shawnaa Supnet.


summary: Facility Evaluation

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Narrative:
On 08/30/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Wayne Aoki at 10:00 am. During the inspection, LPAs met with Administrator, Shawnaa Supnet and inspected the facility inside and out. LPAs reviewed no children's records as there were no dependents in placement and on this date and reviewed two staff personnel records for the facility. LPAs interviewed two staff at 11: AM. LPAs conducted exit interview with Shawnaa Supnet, Administrator at 12: PM. There were no deficiencies to be cited during this inspection.


summary: Facility Evaluation

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Narrative:
On September 22, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II located in Visalia, CA, and met with Tony Gutierrez, Administrator. The purpose of today's inspection is to conduct an Annual/Random inspection. Success in Recovery II has a census of 5 clients and a capacity for 6 clients. A tour of the facility was conducted, a physical plant inspection was completed and included the following observation: All required forms are posted. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. All required forms are posted. The temperature of the facility was a comfortable temperature of 73 degrees. All facility smoke detectors are in appropriate working order and all fire extinguishers are properly charged and serviced. The kitchen has a full-size refrigerator and is operating at safe temperature. The facility maintains an adequate supply of perishable and non-perishable foods and the food menu is available for clients to view. A supply of emergency food is stored at the facility. Knives and sharps are key locked and inaccessible to clients. Chemical, disinfectants, and cleaning solutions are key locked and inaccessible to clients. The dining room is equipped with large table and chairs accommodating of all clients. There are three bedrooms- for double occupancy, all bedrooms are located on one single level. Bedrooms are accommodating of all required furnishings and storage space. All rooms are equipped with a fire alarm and trash can. Six individual beds were observed with appropriate clean linens and Five beds are in good repair. One mattress needs to be replaced due to mattress sinking in the middle. The facility has 2.5 bathrooms, 1.5 are used for clients and 1 for staff, all are operable. All restrooms are stored with hand soap, toilet paper, and paper towels. The facility water temperature is at a safe temperature range. The facility medications are locked and inaccessible to clients. LPA observed medications are centrally stored. The First Aid kit is complete with all first aid items. The facility has a staff office and is inaccessible to clients. No firearms or weapons are allowed in the facility. The facility does not have any types of body of water. Continued on Page 2... Continued from page 1... LPA interviewed one client. LPA interviewed two staff. There are currently Chief Executive Officer, Program Director, Administrator, Social Worker, Clinician, Direct Care Staff, Head of Service. LPA reviewed 5 clients files and Disaster Mass Casualty Plan. A review of the Licensing Information System on September 21, 2023, indicates that all facility staff associated to the agency have DOJ, FBI, and child abuse index check clearances. The facility currently holds a Mental Health Program Approval valid through September 19, 2024. The licensee has obtained National Accreditation through The Joint Commission valid through April 30, 2026. LPA will need to continue the inspection to complete review of staff files, staff interviews, and client interviews. There were no deficiencies issued today. A copy of this report was provided to Tony Gutierrez at the conclusion of the inspection.

met_with: Tony Gutierrez


summary: Facility Evaluation

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Narrative:
On September 25, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery located in Visalia, California to conduct an unannounced visit and met with Elizabeth Reynaga, Assistant Program Director. The purpose of the visit was to continue the Required/Random inspection that was started on 9/22/2023. LPA reviewed 5 staff files, Emergency Intervention Plan, and Board Meeting meeting Minutes. LPA discussed training requirements for facility managers, access to a Nurse, and reporting Incidents in the requirement time frame. LPA Galvan will provide Elizabeth with information regarding regulatory standards. The will be two technical violations issued on today's visit. A copy of this report was provided to Elizabeth Reynaga at the conclusion of this inspection.

met_with: Elizabeth Reynaga


summary: Facility Evaluation

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Narrative:
On 9/29/2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II and met with Facility Representative, Maria Arteaga for the purpose of conducting a Case Management regarding an Incident Report submitted to the department 9/26/2023. It was reported that staff 1 (S1) had a discussion with clients regarding religion, symbolic meaning of the cross, belief, sexual orientation, preference, and gender. After the discussion the view of S1 lead client 1 (C1) to have a discussion with Client 2 (C2), the discussion made C2 uncomfortable causing an issue among C1 and C2. The Administrator (AD) was notified of the incident, immediately AD acted with S1. Based on confidential interview and documents reviewed, concerns surrounding the incident has been addressed and corrected. LPA determined this to not be an immediate risk to the health and safety of clients in care, therefore no deficiency will be issued at this time. An exit interview was conducted, and a copy of the report was provided to Maria Arteaga at the conclusion of the inspection.

met_with: Maria Arteaga


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPA) Reyna Martinez on July 10, 2025 at 12: PM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Tony Gutierrez, Administrator and inspected the facility inside and out. LPA reviewed 1 child record and 2 staff personnel files on site at the facility. LPA reviewed 1 child psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 child on site currently on psychotropic medication. No deficiencies are being cited at this time. LPA conducted an exit interview with Tony Gutierrez, Administrator and a copy of this report was left with facility.


summary: Facility Evaluation

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Narrative:
On September 9, 2025, Licensing Program Analysts (LPAs) Vanessa Galvan and Olivia Medrano traveled to Success in Recovery II located in Visalia, CA, and met with Administrator Tony Gutierrez. The purpose of today's inspection is to conduct an Annual/Random inspection. Success in Recovery II has a census of 4 clients and a capacity for 6 clients. A tour of the facility was conducted, a physical plant inspection was completed and included the following observation: All required forms are posted. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. All required forms are posted. The temperature of the facility was a comfortable temperature of 73 degrees. All facility smoke detectors are in appropriate working order and all fire extinguishers are properly charged and serviced. The kitchen has a full-size refrigerator and is operating at safe temperature. The facility maintains an adequate supply of perishable and non-perishable foods and the food menu is available for clients to view. A supply of emergency food is stored at the facility. Knives and sharps are key locked and inaccessible to clients. Chemical, disinfectants, and cleaning solutions are key locked and inaccessible to clients. The dining room is equipped with large tables and chairs accommodating all clients. There are three bedrooms- for double occupancy, all bedrooms are located on one single level. Bedrooms are accommodating of all required furnishings and storage space. All rooms are equipped with a fire alarm and trash can. Six individual beds were observed with appropriate clean linens and Five beds are in good repair. One mattress needs to be replaced due to mattress sinking in the middle. The facility has 2.5 bathrooms, 1.5 are used for clients and 1 for staff, all are operable. All restrooms are stored with hand soap, toilet paper, and paper towels. The facility water temperature is at a safe temperature range. The facility medications are locked and inaccessible to clients. LPA observed medications are centrally stored. The First Aid kit is complete with all first aid items. The facility has a staff office and is inaccessible to clients. No firearms or weapons are allowed in the facility. The facility does not have any types of body of water. Continued on Page 2... Continued from Page 2... There are no pets at the facility. Facility has cameras in common areas. Facility appears to be meeting the terms and conditions of their license. LPAs reviewed 4 client files and 5 staff files. An annual continuation will be completed on another date. There were no deficiencies to be cited on this date. This report was reviewed and provided to Tony at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On September 15, 2025, Licensing Program Analysts (LPA) Vanessa Galvan and Olivia Medrano traveled to Success in Recovery located in Visalia, California to conduct an unannounced visit and met with Administrator, Tony Gutierrez. The purpose of the visit was to complete the 2-year required inspection that started on 09/09/2025. There are currently Chief Executive Officer, Administrator, Social Worker/Head of Service, Clinician, and Direct Care Staff. LPAs reviewed 4 client and 5 staff files. A review of the background clearances was conducted September 9, 2025, indicates that all facility staff associated with the agency have DOJ, FBI, and child abuse index check clearances. The facility currently holds a Mental Health Program Approval valid through September 19, 2025. The licensee has obtained National Accreditation through The Joint Commission valid through April 30, 2026. The facility is being cited for CCR, Title 22, Safeguards for Cash Resources, Personal Property, and Valuables, Section 80026(h)(1), ILS, Title Building and Grounds 87087(e), and 80087(a), Health and Safety Code Section 1565(e)(2) and 1565(e)(3) and Technical Violation CCR, Title 22, Safeguards for Cash Resources, Personal Property, and Valuables,Section 80026(h)(1)(B). This report was reviewed and provided to Tony Gutierrez at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On October 24, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II located in Visalia, CA, and met with Administrator Tony Guiterrez conduct an unannounced complaint inspection. The purpose of the inspection was to clear a Plan of Correction (POC). LPA reviewed documentation to confirm that the POC was cleared. No deficiencies were issued or observed at this time. An exit interview was conducted, a copy of this report and the Letter of Deficiency citations cleared were provided to Tony Guiterrez at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On November 19, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II located in Visalia, CA, and met with Administrator, Tony Gutierrez conduct an unannounced complaint inspection. The purpose of the inspection was to clear a Plan of Correction (POC). LPA reviewed documentation and conducted a physical plant walk through to confirm that the POC were cleared. No deficiencies were issued or observed at this time. An exit interview was conducted, a copy of this report and the Letter of Deficiency citations cleared were provided to Tony Gutierrez at the conclusion of the inspection.


raw_content:
Investigation Findings:
13On November 19, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II located in Visalia, CA, to conduct an unannounced inspection and met with Administrator, Tony Gutierrez and Head of Service, Rilee Hopper. The purpose of the inspection is to deliver the findings for the above allegations. The above allegations were referred to Community Care Licensing for an investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on confidential interviews and other information obtained, the Department has made the following determination. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. A copy of this report and appeal rights were discussed and provided to Tony Gutierrez at the conclusion of the inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/24/2025 and conducted by Evaluator Vanessa Galvan PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:SUCCESS IN RECOVERY IIFACILITY NUMBER: ADMINISTRATOR:LUIS TONY GUTIERREZFACILITY TYPE: ADDRESS: PACKWOOD ST.TELEPHONE: (559) 635- CITY:VISALIASTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 11/19/ UNANNOUNCEDTIME BEGAN: 02: PM MET WITH:Tony Gutierrez and Rilee Hopper TIME COMPLETED:03: PM 9Staff use inappropriate forms of discipline with minors. The facility has cameras that record audio. Minors are forced to get a haircut not of their choice. INVESTIGATION FINDINGS: 13On November 19, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II located in Visalia, CA, to conduct an unannounced inspection and met with Administrator, Tony Gutierrez and Head of Service, Rilee Hopper. The purpose of the inspection is to deliver the findings for the above allegations. The Department has investigated the above complaint allegations. During the investigation, LPA conducted confidential interviews and reviewed files. Based on information obtained and confidential interviews it was determined that the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. The agency is being cited for Title 22, Interim Licensing Standards for Short-Term Residential Therapeutic Program, Article 06. Continuing Requirements, Personal Rights(c)(16) and Personal RIghts (c)(1) See Attached LIC 9099D for further information. An exit interview was conducted discussing this report and the appeal rights. A copy of this report and appeal rights were provided to Tony Gutierrez at the conclusion of the inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: SUCCESS IN RECOVERY IIFACILITY NUMBER: 547202724

met_with: Tony Gutierrez and Rilee Hopper


summary: Facility Evaluation

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Narrative:
On September 15, 2025, Licensing Program Analysts (LPAs) Vanessa Galvan and Olivia Medrano traveled to the Success in Recovery Short-Term Residential Therapeutic Program in Visalia, CA, to conduct Case Management and met with Administrator, Tony Gutierrez. The purpose of the inspection is to discuss two incident reports that were submitted to the department. The incident reports disclosed that Staff 1 (S1) administered medication to 2 out of 4 clients without court order or parental consent. (See LIC 811 for confidential names) During the inspection, the LPAs conducted confidential interviews and protocol for administering medication. The Agency is being cited for Interim Licensing Standards, Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Children's Records Section 87070(b)(13). (See LIC 809D) An exit interview was conducted to discuss this report, LIC 811, and appeal rights. A copy of this report, appeal rights, and LIC 811 were provided to Tony Gutierrez at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On January 4, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery Short-Term Residential Therapeutic Program located in Visalia, CA, to conduct a Case Management and met with Administrator, Tony Gutierrez. The purpose of the inspection is to discuss an incident report that was submitted to the department on 12/27/2023 regarding a medication error. On 12/25/23, The House Administrator failed to administer morning medications to all clients in care. The error was not noticed until evening medications were dispensed at approximately 7:30pm by direct care staff. Clients did not report feeling any changes or side effects due to the missed dose. LPA discussed with the Administrator the concerns of administering medication and the importance of medication oversight. Based on interviews and information obtained, the Agency is being cited for Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Health Related Services. An exit interview was conducted to discuss this report and appeal rights. A copy of this report, appeal rights were provided to Tony Gutierrez at the conclusion of the inspection.

met_with: Tony Guiterrez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Reyna Martinez and Briana Placencia on August 7, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Tony Gutierrez, Administrator and inspected the facility inside and out. LPAs reviewed 1 child record and 2 staff personnel files on site at the facility. LPAs reviewed 1 child psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed 1 child on site currently on psychotropic medication. A deficiency is being cited on today's visit under Code of Regulations (CCR), Title 22, 80087(a) Buildings and Grounds on the attached LIC809-D page. LPAs conducted an exit interview with Tony Gutierrez, Administrator and a copy of this report and appeal rights was left with facility.


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13On January 22, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery II located in Visalia, CA, to conduct an unannounced inspection and met with Administrator, Tony Gutierrez. The purpose of the inspection is to deliver the findings for the above allegations. The Department has investigated the above complaint allegations. During the investigation, LPA conducted confidential interviews and reviewed files. Based on information obtained and confidential interviews it was determined that the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. The agency is being cited for Title 22, Interim Licensing Standards, Article 06., sections Personal Rights(c)(15), Personal Rights (c)(16). See Attached LIC 9099D for further information. A copy of this report and appeal rights were provided and discussed to Tony Gutierrez at the conclusion of the inspection via email due to printer error. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Vanessa Galvan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: SUCCESS IN RECOVERY IIFACILITY NUMBER: 547202724


summary: Facility Evaluation

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Narrative:
On 04/09/2026, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Success in Recovery II Short-Term Residential Therapeutic Program located in Visalia, CA, to conduct an unannounced Case Management and met with Shawnaa Supnet, Administrator. The purpose of the inspection is to discuss an incident report (2853-FN) that was submitted to the department on 04/02/2026 regarding a medication error. On 03/28/2026, 03/29/2026, and 03/30/2026, Staff 1 (S1) and Staff 2 (S2) failed to administer client 1's (C1) (see LIC 811 for confidential names) evening medication. The medication error was noticed on 03/31/2026. C1 did not report feeling any changes or side effects due to the missed dosage. Administrator met with S1 and counseled S1 on medication procedures. Will meet with S2 upon returning to work after leave. Administrator has scheduled all staff to complete medication training that is scheduled for April 22, 2026. Based on document review, the Agency is being cited for Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Health Related Services. An exit interview was conducted to discuss this report, appeal rights, and LIC 811. A copy of this report, appeal rights, and LIC 811 were provided to Shawnaa Supnet, Administrator at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/09/2026, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Success in Recovery II Short-Term Residential Therapeutic Program located in Visalia, CA, to conduct an unannounced Case Management and met with Shawnaa Supnet, Administrator. The purpose of the inspection is to discuss an incident report (2819-FN) that was submitted to the department on 03/24/2026 regarding a medication error. On 03/13/2026 and 03/16/2026, Staff 1 (S1) and Staff (S2) failed to administer Client 1's (C1) (see LIC 811 for confidential names) morning and evening medication. The medication error was noticed on 03/17/2026. C1 did not report feeling any changes or side effects due to the missed dosage. Administrator met and counseled S1 and S2 on medication procedures. Administrator has scheduled all staff to complete medication training that is scheduled for April 22, 2026. Based on document review, the Agency is being cited for Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Health Related Services. An exit interview was conducted to discuss this report, appeal rights, and LIC 811. A copy of this report, appeal rights, and LIC 811 were provided to Shawnaa Supnet, Administrator at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/17/2026, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Success in Recovery II Short-Term Residential Therapeutic Program located in Visalia, CA, to conduct an unannounced Case Management and met with Britany Arzola, Youth Counselor II and Shawnaa Supnet, Administrator. The purpose of the inspection is to discuss an incident report (2899-FN) that was submitted to the department on 04/13/2026 regarding a medication error. On 04/09/2026, Client (C1) was given Client (C2's) medication in error. Staff (S1) (see LIC 811 for confidential names list) noticed the medication error prior to C1 consuming the medication and instructed C1 to return the medication, however C1 proceeded to take the medication. Per Youth Counselor II (S2), C1 reported no side effects other than feeling anxious after finding out they were dispensed the wrong medication. Since the incident, C1 has reported feeling fine. S2 did not observe any side effects in behavior. Administrator did contact prescribing pharmacist to see if any further action was needed and pharmacist reported no. Administrator met with S1 and counseled S1 on medication procedures. Administrator has scheduled all staff to complete medication training that is scheduled for April 22, 2026. Based on document review, the Agency is being cited for Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Section Health Related Services and being issued a civil penalty. An exit interview was conducted to discuss this report, appeal rights, and LIC 811. A copy of this report, appeal rights, and LIC 811 were provided to Shawnaa Supnet, Administrator at the conclusion of the inspection.