summary: Facility Evaluation

raw_content:
Narrative:
On 04/18/23 at 8: AM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted an unannounced Annual Inspection at the facility. LPAs met with Melissa Williams, Administrator. This STRTP is licensed to serve up to six (6) ambulatory children ages 12-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are four (4) minors and one (1) non-minor dependent currently in placement. This facility is a 3-bedroom single story home. There are no bodies of water in the premises. LPA Silva conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and was measured at 120 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file. According to the facility manager, there have been no manual restraints recorded in the last 24 months. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Client Records LPA Silva reviewed five (5) client records. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. During records review, all five of clients' cash resources log do not show disbursements and balances. However, Administrator showed disbursement logs in a different form. Staff Records LPA Silva reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Although training certificates were on file, documentation of initial training were not found in the staff files. LPAs interviewed three (3) staff members. LPAs were unable to interview clients due to all five clients were in school at the time of inspection. No deficiency citation was issued during today's inspection. However, a Technical Violation and a Technical Assistance were issued see LIC9102TV and LIC9102TA. An exit interview was conducted, and a signed copy of this report, LIC9102TV, LIC9102TA,and LIC811 were provided to the Administrator..

visit_type: Annual


state: CA

facility_name: WENDELL HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On 5/19/23 at 9: AM, Licensing Program Analyst (LPA) Irene Yamamoto conducted a case management inspection at the facility to assess an Enhanced Civil Penalty (ECP). LPA Yamamoto discussed the following with the facility representative named above. On 5/8/23, the Department concluded a complaint investigation on a Short-Term Residential Therapeutic Program (STRTP) which alleged that facility staff did not prevent client from being sexually abused while in care. Two clients were placed together in one bedroom even though there was no commonality in their ages, behaviors and background information to make them suitable roommates. The older client has a known dangerous sexual propensity towards younger children. Multiple staff expressed this concern to the Administrator, but clients were still placed together despite staff concerns. Based on the consistent statements obtained and records reviewed during the investigation, there was a preponderance of evidence that supported the allegation. The allegation was substantiated, and the facility was cited for Neglect/Lack of Supervision under California Code of Regulations (CCR) 80078(a). The Department has concluded an analysis and determined that an Enhanced Civil Penalty is warranted. Under Health and Safety Code section 1548(f)(1)(C)(ii), a violation that the Department determines results in physical abuse as defined in section 1548(f)(2) to a child receiving care through a STRTP, there shall be a civil penalty of $2500.00. Under H&S 1548, "physical abuse" includes neglect as defined in 11165.2 of the Penal Code, when the person responsible for the child's welfare is a licensee, administrator, or employee of any facility licensed to care for children. A copy of this report, the Confidential Names Form, Appeal Rights, and the signed LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Melissa Williams, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles, and Timika Martin on 08/11/23 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Desiree Gonzalez, Facility Manager and Melissa Williams, Administrator, and inspected the facility inside and out. LPAs reviewed three (3) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed three (3) of children's psychotropic medications and medication records. LPAs interviewed two (2) of staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed three (3) children currently prescribed psychotropic medications. No deficiencies are being cited at this time. LPA conducted exit interview with Melissa Williams, Administrator and provided a copy of this licensing report.

met_with: Melissa Williams


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva, Juliet Robles & Timika Martin on 09/05/24 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Melissa Williams, Administrator, and inspected the facility inside and out. LPAs reviewed two (2) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed two (2) of children's psychotropic medications and medication records. LPAs interviewed two (2) staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed one (1) of child currently prescribed psychotropic medications. One child was unavailable for interview at the time of inspection. No deficiencies are being cited at this time. LPAs conducted exit interview and provided a copy of this report to the Administrator, Melissa Williams.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/03/25 at 9: AM, Licensing Program Analysts (LPAs) Olena Maico conducted an unannounced Annual Inspection at the facility. LPAs met with Melissa Williams, Administrator and Desiree Gonzalez, Facility Manager. This STRTP is licensed to serve up to six (6) ambulatory children ages 12-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are 2 minors currently in placement and one of them is on AWOL status. This facility is a 3-bedroom single story home. There are no bodies of water on the premises. There are no ammunition and firearms in the facility per the administrator's statement. LPA Maico conducted a walk-through of the entire facility alongside with the Facility Manager. LPA requested LIC 500, LIC 9020, LIC 610C, LIC 309 and LIC 308 as well as the Emergency Drill records and Board Meeting records to be provided to the LPA. LPA compared Guardian roster to the facility roster and all the staff has clearance through the Guardian. Facility has current CARF accreditation expiring January 31st 2028, as well as Mental Health Services approval expiring November 16 2025. LPA observed the license, facility sketch, Personal Rights, Emergency Disaster form, Foster Youth Bill of Rights, Complaints/Grievance policy, menu and activity schedule posted in prominent, publicly accessible location in the facility in the living room and the kitchen area. Overall, the facility is clean, safe, sanitary and in good repair. Facility just resurfaced their floor and when LPA arrived facility was organizing furniture in the rooms. Physical Plant Facility has no cameras on premises. Disinfectants, cleaning solutions and sharps are kept inaccessible. Sharps are locked in the kitchen closet. Facility has non-perishable food for at least one week and perishable food for at least two days in the fridge and meet the licensing standards. Medications are centrally stored in the office of the facility. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguisher are fully charged and checked by the fire department October 2024. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and was measured at 120 degrees F. All sinks, showers and toilets were in working order. Currently each client has their own bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Each client has the non-slip rug to use after shower. Emergency exits are free from obstruction. Kitchen had adequate number of dishes for the clients served. There are couches in the living room and the dining room to accommodate the clients. Fire place in the living room has cover and inaccessible to clients. Windows have blinds for client's privacy. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures and the procedures and forms are posted on the wall in the prominent place at the facility. Clients have the cash resources. Administrator provided LPA with minutes from 2024, the minutes for current period are being created. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. LPA issued a technical assistance to the facility to comply with the regulation on updating the plan yearly and providing e-mail and phone numbers for the assigned personnel. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Head of Service oversee the therapeutic services for the clients Clients also visit Henrietta Weill Child Guidance Clinic for the therapeutic services. Client Records LPAs reviewed two client records. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. FC1 is on AWOL status and FC2 did not have TB test assessment on file. FC1 and FC2 psychotropic medication log was missing initials for multiple dates for the medication taken. FM checked the notes and medication was either taken or refused by the clients, but the log was not marked properly. Facility is issued deficiency for not following the psychotropic medication log procedures. Three (3) deficiency citations and a two Technical Assistance were issued during today's inspection, see LIC809D and LIC9102TA. Plan of Corrections were discussed with the Administrator. LPA will return on another day to complete the inspection and review Emergency Intervention Domain and Staff files. An exit interview was conducted, and a signed copy of this report, LIC809D, LIC811 and appeal rights were provided and explained to the Administrator.

met_with: Desiree Gonzalez, Facility Manager Melissa Williams, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 04/07/25 at 9: AM, Licensing Program Analysts (LPAs) Olena Maico conducted an unannounced annual Inspection at the above facility. LPA met with Melissa Williams, Administrator. LPA continued annual inspection LPA started on 04/03/2025. LPA requested 5 staff files as well as the Emergency Intervention Plan training for the staff and the certificates and the certificate for the trainer. LPAs reviewed five (5) staff records (See LIC List of Confidential Names dated 04/07/25). LPA reviewed staff health screening and TB test results, background clearance (DOJ, FCBI and CACI), driver license records, application, resume and educational records, as well as training records which includes trauma informed care, cultural awareness, behavioral support for youth, CPR/First Aid. LPA reviewed Administrator qualifications and they are in compliance with CCLD requirements. Head of Service flexibility request was approved for the facility by the Department of Health Care Services. Head of Service does meet education and experience requirements. LPA reviewed Emergency Intervention staff training and the training curriculum. LPA also requested the training instructor certificate from the Administrator, who conducts the MAB training for the staff. LPA did not observe training certificates for the MAB in the staff S3,S4,S5 files. LPAs interviewed two (2) staff members. LPA interviewed one (1) client. Two (2) deficiency citations and two (2) Technical Violations were issued during today's inspection, see LIC809D and LIC9102TV. Plan of Corrections were discussed with the Administrator. Copy of this report and LIC 809D was explaind and given to the Administrator as well as appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
On April 22, 2025 at 11: AM, Licensing Program Analyst (LPA) Olena Maico conducted an unannounced inspection to the above named STRTP to verify proof of corrections for the deficiencies cited on 4/03/25 with a Plan of Correction (POC) due dates of 4/17/25 and and deficiencies cited on 04/07/25 with the proof of correction due 4/21/23. Two out of five (5) POC's were due on 4/17/25. Two other deficiencies were due on 04/21/25. As of today (4/22/25), the licensee has not submitted four (4) out of five (5) proof of corrections specified in the Facility Evaluation Reports dated 4/03/25 and 4/07/25. That warranted POC visit to the facility. LPA was able to verify and clear 4 citations by reviewing records provided by the staff and the Administrator (one was due on 04/17/25 and one is due 04/24/25). Following deficiency is still outstanding : ILS 87095.65(d) The licensee must maintain a written record of the facility staff training. (due 4/21/25) - Emergency Intervention Training. LPA assessed penalty on the outstanding citation due to them not being cleared by the POC due date. A signed copy of this report was issued and explained to the Administrator along with LIC 421FC (Civil Penalty Assessment - Failure to Correct forms) with appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
On May 2, 2025, at 11:30 a.m., Licensing Program Analysts (LPAs) Ashley Ruacho and John Bonilla conducted an unannounced Case Management inspection at Wendell House, a Short-Term Residential Therapeutic Program, for the purpose of delivering amended findings related to complaint #32-CR-20250103170459. LPAs met with Desiree Gonzalez, Facility Manager. During this inspection, LPAs went over the amended findings with the STRTP representative and the STRTP was issued a deficiency. Please refer to LIC9099-D (deficiency page). A signed copy of all licensing reports were provided to Ms. Gonzalez. An exit interview was conducted. Appeal rights were given and explained.

met_with: Desiree Gonzalez, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On May 2, 2025, at 11:30 a.m., Licensing Program Analysts (LPAs) Ashley Ruacho and John Bonilla conducted an unannounced collateral inspection at Wendell House, a Short-Term Residential Therapeutic Program, for the purpose of interviewing a current client formerly at a different facility. LPAs met with Melissa Williams, Administrator. During this inspection, LPAs interviewed client 1 (C1) (See LIC Confidential Names list dated 05/02/25). A signed copy of this report and LIC811 were provided to Ms. Williams. An exit interview was conducted. No further action required.


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday, May 3, 2025, at 01:00 p.m., Licensing Program Analyst (LPA) John Bonilla conducted an unannounced inspection at Wendell House, a Short-Term Residential Therapeutic Program (STRTP). LPA met with Desiree Gonzalez, Facility Manager. The purpose of the inspection at the facility was to follow up on a Plan of Correction (POC) for a deficiency issued under Interim Licensing Standards (ILS), section 87061(i)(7)(A)(C), on 05/02/25 with a POC due date of 05/30/25, for the following: Licensee did not include the date and time of other manual restraints involving same child in the past 24 hours; and description of what manual restraints were used, and how long the child was restrained. The deficiency has been corrected per POC. A signed copy of this report and POC cleared letter was provided to the Facility Manger and an exit interview was conducted. No follow-up required.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/10/25 at 11: AM, Licensing Program Analyst (LPA) Olena Maico conducted an unannounced case management inspection at the above facility and met with Melissa Williams, Administrator. The purpose of the inspection was to follow up on a Special Incident Report (SIR) received by the Department on 08/03/25. The SIR stated that earlier in the day, C1 (refer to Confidential Names List LIC811 dated 09/10/25) had C2's phone. C1 reported to Staff that he saw pictures of other peer resident's on C2's phone. C1 stated that the pictures were inappropriate and that was very upsetting to him. The facility filed SCAR report. LPA interviewed C1, Administrator during the visit. C2 is on AWOL status and unavailable for the interview. Based on the information collected and observed LPA did not find the evidence of neglect or lack of supervision. No deficiencies cited. The copy of this report and LIC 811 was given to the facility representative.

met_with: Melissa Williams, Administraor


summary: Facility Evaluation

raw_content:
Narrative:
On December 3rd 2025, at 11: AM Licensing Program Analyst (LPA) Olena Maico made an unannounced visit to the above facility for the purpose of a case management inspection. The purpose of the inspection is to follow-up on a Special Incident Report (SIR) received by the Department on November 19th,2025. LPA reviewed FAS and the complaint was opened on the same incident. LPA will follow up once the complaint is completed. NO deficiencies issued during the visit. Copy of this report was provided to the facility representative.

met_with: Juan Aguayo, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles on 07/16/2025 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Facility Manager, Desiree Gonzalez, and inspected the facility inside and out. LPAs reviewed four (4) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed four (4) of children's psychotropic medications and medication records. LPAs interviewed one (1) staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed one (1) child currently prescribed psychotropic medication. During the inspection, the LPAs observed deficiencies (see attached 809D). A Technical Advisory was issued (see LIC 9102). Plan of corrections were discussed, and appeal rights were provided. LPAs provided a copy of this licensing report and appeal rights to Desiree Gonzalez, Facility Manager.

met_with: Desiree Gonzalez


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday, October 26, 2021 at 1:15 pm, Licensing Program Analyst (LPA) Belinda Gilmer made an unannounced visit to this facility and met with Direct Care Staff, Sulma Navarro. The purpose of this visit was to discuss some documents Community Care Licensing received on September 8, 2021. However, when LPA arrived there was one resident and one Direct Care Staff working at the facility. LPA was later joined by Facility Director Jaye Williams at 2:01 pm, who addressed the plan of corrections. The Administrator Mrs. Williams also arrived at the facility during this visit. As per interim Licensing Standards Article Personnel Requirement the licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present: This facility will be cited per the above violation. An exit interview was held with Direct Care Staff Sulma Navarro and a copy of the facility evaluation report and the Confidential names list.

met_with: Sulma Navarro


summary: Facility Evaluation

raw_content:
Narrative:
On May 8, 2023 at 10:00AM, Licensing Program Analyst (LPA) Irene Yamamoto conducted a case management inspection at the facility. During this inspection, LPA met with the facility representative named above. The purpose of the inspection is to issue citations for the following deficiencies observed during a review of records by the Department. - Accepting placement of a client who did not meet the age requirement of the facility. - Needs and Services Plan of client was not signed by client and the clients' authorized representative. These violations pose an immediate and/or potential Health, Safety, or Personal Rights risk to clients in care. Deficiency citations were issued under California Code of Regulations (CCR) 80010 (a) Limitations on Capacity and Ambulatory Status and Interim Licensing Standards (ILS) 87068.2(f) Needs and Services Plan. A Plan of Correction was discussed with the facility representative. Copies of the following were provided at the conclusion of the inspection: LIC 809, LIC 809-D and LIC 811. Appeal rights given and explained.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
This LPA conducted an investigation into the above allegation(s). The investigation included, but was not limited to, a review of facility records such as client needs service plans, current CFTs, SIR's, and Daily Activity reports. This LPA also conducted interviews with four staff members-S1, S3, S4 on 11/25/25, and S2 on 3/10/26-and with two of the four clients (C1 and C3) on 11/25/25. Statements were not obtained from C4 and C2, as they declined to participate. (See Confidential Names Form LIC 811, dated April 3, 2026.) The Following Allegation(s) were reported: 1. The staff did not prevent the youth from viewing inappropriate content on an electronic device. Staff denied the allegation that they failed to prevent a youth from viewing inappropriate content on an electronic device. Staff reported that the facility maintains a minimum of two staff members on duty at all times, with staffing levels adjusted in accordance with program activities and operational needs. Staff stated that they remain actively engaged with clients throughout the day and that this level of supervision is intended to mitigate the risk of inappropriate or disruptive behavior. Staff acknowledged that there have been occasions in which clients accessed inappropriate content on their personal electronic devices. Staff indicated that when such incidents occur, they intervene immediately by redirecting the client and ensuring the content is no longer accessible. Staff further stated that all incidents of this nature are reported to upper management, mental health personnel, the client's therapist, and any other relevant supporting agencies, in accordance with internal reporting procedures. Staff emphasized that oversight of electronic device use has inherent limitations because the devices involved are personally owned and provided by the clients' parents or relatives. Continued... C1 and C3 reported that they enjoy residing at the STRTP and stated that there are typically three or more staff members present who supervise clients. C3 denied the allegation and stated that clients are consistently supervised by staff, who also participate in activities with them. C3 further reported that they have never observed or heard of clients engaging in inappropriate behavior. C1 reported that they have their own iPad/iPhone, which was purchased by their parents, and that they use the device to watch movies and play games. When asked whether they had ever viewed inappropriate content on their iPad, C1 initially denied doing so but later acknowledged that they had viewed inappropriate content on one occasion, stating that it occurred accidentally. C1 reported that staff redirected them at the time and informed them that inappropriate content was not permitted and that they needed to select different material. 2. The staff did not follow reporting requirements. Staff refuted the allegation, reporting that the incident was communicated to Community Care Licensing (CCL) in a timely manner and in accordance with STRTP Interim Licensing Standards. Staff stated that they adhered to the facility's internal reporting procedures and notified all required parties, including upper management, mental health personnel, and other relevant agencies, as outlined in regulatory and program expectations. Therefore, based on the information received, the above allegation(s) are determined to be unsubstantiated. Although the allegation(s) may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred; therefore, the allegation is found to be unsubstantiated. Appeal Rights were provided and discussed with the Foster Family Agency. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Executive Director.

Investigation Findings:
13On April 3, 2026, at 5: PM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with the Facility Executive Director, Jaye Williams. The inspection aimed to deliver the finding(s) regarding the above-referenced complaint allegation(s). On October 17, 2025, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): The staff did not prevent youths from viewing inappropriate content on an electronic device, and the staff did not follow reporting requirements. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Winston Moroney 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: WENDELL HOUSEFACILITY NUMBER: VISIT DATE: 04/03/2026

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

report_type: Complaint Investigation

met_with: Jaye Williams

complaint_status: unsubstantiated


raw_content:
Narrative:
This LPA conducted an investigation into the above allegation(s). The investigation included, but was not limited to, a review of facility records such as client needs service plans, current CFTs, SIR's, and Daily Activity reports. This LPA also conducted interviews with three staff members S1, S2, and S3 on 11/25/25, and with four of the six clients (C1, C2, C3, and C6) on 11/25/25. Statements were not obtained from C4 and C5, as they declined to participate. (See Confidential Names Form LIC 811, dated April 3, 2026.) The Following Allegation(s) were reported: 1. The staff did not provide adequate supervision, resulting in minors engaging in inappropriate behavior. Staff members S1, S2, and S3 refuted the allegation and stated that they consistently engage with all clients throughout the day. Staff reported that they conduct bedroom checks every thirty minutes to an hour or less, depending on each client's individual needs. Staff stated that all personnel are trained in Trauma Informed Care and understand the importance of maintaining a safe, supportive, and predictable environment for clients. Staff further indicated that no clients have reported incidents consistent with the allegation. Staff reported that the facility maintains appropriate staffing levels at all times. They stated that two or more staff members are scheduled per shift, and that staffing patterns are adjusted based on client needs and the operational requirements of the STRTP. Staff emphasized that staffing decisions are made to ensure consistent supervision, client safety, and adequate support in accordance with Title 22 and STRTP Interim Licensing Standards. Continued... S3 reported that on November 12, 2025, at approximately 10: PM-prior to the start of their scheduled shift-they were conducting room checks when they observed that Client 2 (C2) was not in their assigned bedroom. S3 stated that they searched C2's closet, under the bed, and the facility bathroom but were unable to locate C2. S3 continued checking the remaining bedrooms and ultimately located C2 in Client 1's (C1) closet with a blanket covering them. S3 stated that they did not observe any wrongdoing by either client; however, they did observe C2 adjusting their pants when removing the blanket. S3 reported that after speaking with C1, C1 stated that they had been playing their game when C2 entered the room because they could not sleep. According to C1, C2 sat next to them watching them play, and when they heard staff conducting room checks, C2 attempted to hide under the blanket to avoid being caught out of their room. S3 reported that all required supporting agencies were notified of the incident on November 13, 2025, in accordance with STRTP reporting requirements. Information obtained from C1 and C2 refuted the allegation. Both clients reported that there are typically three to four staff members supervising clients, depending on the activities taking place at the STRTP. C1, C2, C3, and C6 reported that they have not heard or witnessed any inappropriate behavior among clients. C1 denied being inappropriately touched by anyone at the facility and stated that they feel safe living at the STRTP and get along well with both clients and staff. Therefore, based on the information received, the above allegation(s) is determined to be unsubstantiated. Although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred; therefore, the allegation is found to be unsubstantiated. Appeal Rights were provided and discussed with the Foster Family Agency. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Executive Director.

Investigation Findings:
13On April 3, 2026, at 4: PM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with the Facility Executive Director Jay Williams. The inspection aimed to deliver the finding(s) regarding the above-referenced complaint allegation(s). On November 24, 2025, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): The staff did not provide adequate supervision resulting in minors engaging in inappropriate behavior. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Winston Moroney 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: WENDELL HOUSEFACILITY NUMBER: VISIT DATE: 04/03/2026

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


facility_name: YOSEMITE TREATMENT CENTER

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
During the months of July-September 2024, 11 (24)hour serious incident reports were submitted to the Department without corresponding final reports being submitted. There were five incidents involving restraints which were not reported to the Department. Four staff were unable to explain to the LPA what the process is to report incidents. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Three citations are being issued for violating Title 22, Division 6, Section 80028(a): Responsibility for Providing Care and Supervision, Interim Licensing Standards (ILS) Section 87072(c)(17): Personal Rights, and Title 22, Division 6, Section 80061(b). A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. Regarding allegations of staff not addressing minors' health care needs, interviews with staff and clients indicated the facility has a medic on site. However, some interviews denied medical care as being available for clients when asked. Staff and clients reported that clients had access to three meals and a snack daily, but statements differed regarding the quality and quantity of the snacks, and the process for how to address when a client misses a meal. One staff reported that if a client acts up, they are not given a meal. Interviews and record review were inconsistent regarding the allegations that staff inappropriately restrained a minor resulting in injuries, and staff handled minor in a rough manner. One staff reported observing another staff push a client against a wall, however, no clients interviewed corroborated this statement. Regarding the allegation of staff hitting a minor with a vehicle resulting in injuries, interviews were inconsistent. One client reported having stolen a golf cart at the facility, but not getting injured. No incident report was submitted to confirm any other client or staff involvement. Regarding the allegation of staff not intervening when a minor engaged in self-harm, interviews were inconsistent. An incident did occur in the stabilization room involving electrical wiring. Client and staff interviews provided inconsistent statements regarding whether the wiring was exposed or not, and accessible to clients. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 12.19.24 for the purpose of delivering findings for the complaint investigation. LPA met with NAME, TITLE. LPA Thorn and LPA Lyta Vue conducted the complaint investigation. LPA opened the investigation with the facility on 10.11.24 and met with Paige Woodard, Program Director and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed One Probation Officer, Three staff, and one client. LPA reviewed records including: Needs and Services Plan for one client, Intake form for one client, LIC 500, Placing Agency Contacts, Staff Training Log, and Incident Reports, and a video. Regarding a lack of supervision for the client the facility submitted an incident report stating that a staff was disciplined for sleeping on night shift. It was alleged that staff made inappropriate comments toward the minors. Client and three staff interviews corroborated that on occasion, staff speak inappropriately to the clients, or with a derogatory tone. Two staff spoke of this being an ongoing problem and staff need more training. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YOSEMITE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 12/19/2024

met_with: Paige Woodard, Program Director


raw_content:
Narrative:
It was alleged that a minor was sexually abused in care by another minor. All confidential interviews with staff and 5 of 6 youth interviewed indicate that they had no knowledge of this incident. Those staff and youth interviewed stated that neither minor had reported any concerns or complaints about being sexually harassed or abused by another youth in care. Records reviewed showed no indications of concerns or complaints being brought to staffs' attention and that both minors ran away from the facility. Three confidential interviews revealed that both youths stated that they hated being at the facility and would often talk about leaving on their own. Six of Seven staff interviewed explained supervision to be appropriate and that protocol about supervision was in place and being followed. Based on LPA's interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
On 08.28. Licensing Program Analyst (LPA) NAME arrived unannounced at the facility on for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Thorn conducted the complaint investigation. LPA opened the investigation with the facility on 06.12.25 and met with Paige Woodard, Program Director. During the course of the investigation, LPA interviewed 6 youth and 8 staff. LPM Hillary Hall conducted one other confidential interview. LPA reviewed records from the facility including Placement Roster, prior complaint history, Serious Incident Reports, CFT notes, and case notes for 2 youth, and LIC 500. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YOSEMITE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 08/28/2025


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 1/16/2024, Licensing Program Analyst (LPA) Tina Thorn and Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility and met with Paige Woodard, Administrator. The purpose of the visit was to conduct a Required, Two year Annual Inspection of the facility. The facility was licensed 12/22/2022. LPA and LPM utilized the CARE Tool to complete the inspection. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized, and maintained an acceptable room temperature. The facility is on a large campus with many buildings. Each client has their own bedroom in a dorm like setting. The dorm has 6 client bathrooms. All bathrooms were observed to be clean and fully functioning. The dining hall is separate from the dorms. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The facility has a properly fenced pool, and opportunities for clients to access sports equipment. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. Smoke alarms, fire extinguishers and a first aid kit were observed to be current and within regulations. LPA observed the kitchen to have 3 restaurant sized refrigerators and freezers with at least 2 days of perishable food and 7 days of non-perishable food on hand. LPA observed client medications were stored in a locked file cabinet in the locked office. Client files are primarily electronic with paper files for clients locked in the Head of Service's office. The facility has no outstanding fees. The facility currently has 16 clients, with a licensed maximum capacity of 16. Staff to client ratio is 1 to 4. LPA reviewed 5 staff files. Staff clearances were reviewed and all staff had required initial and annual training. All First Aid and CPR certifications were up to date for staff. LPA interviewed three staff on site. Continued on 809C Continued from LPA Thorn interviewed three clients. LPM reviewed five client files. All clients had signed Admission Agreements on file. Needs and Service Plans (NSP) for clients were reviewed. Three out of five clients did not have an initial NSP completed within 30 days. Five out of five clients' NSP were not updated every 30 days. Some NSP were duplicated. Four out of five NSP were not signed by the client. Five out of five NSP were not signed by the authorized representative. The facility did not have evidence of attempting to obtain signatures from authorized representatives. Clients were current on CHDP physical exams and dental exams. Clients prescribed psychotropic medications had current JV-220's on file. Facility is issued three citations per Interim Licensing Standard Sections 87070(c)(1) Children's Records, 87068.2(a) Needs and Service Plans, and Section 87068.3(a) Modifications to Needs and Service Plans A signed copy of this LIC-809, LIC-809C, and LIC 809D, report was provided to the Administrator. An exit interview was conducted. Appeal rights were provided

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following

met_with: Paige Woodard, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 05.23. Licensing Program Analyst (LPA) Tina Thorn arrived at facility unannounced for the purpose of a Case Management regarding a record review and met with Program Director. LPA interviewed Program Director and placing agency regarding timely medical records for youth. Program Director had indicated that there was a delay in obtaining the needed exams due to problems they have been having with both insurance coverage payments and delays due to providers not being able to schedule out appointments for clients within the 30 days. Program Director agreed to CC LPA on all emails sent to probation around this issue and to send a list of all clients who are being affected by the delay. A plan to mitigate the lack of timely exams has been implemented. No citations issued at this time.

met_with: Paige Woodard,Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 06.20. Licensing Program Analyst (LPA) Tina Thorn arrived unannounced for a case management inspection for the purpose of following up on a Serious Incident Report. LPA met with Courtney Costello, Head Of Service and Paige Woodard, Program Director and reviewed the file for one client and interviewed the administrator and client. No citation was issued at this time

met_with: Courtney Costello, Head of Service, Paige Woodard, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 12.03.25, Licensing Program Analysts (LPAs) Tina Thorn and Lyta Vue arrived unannounced at the facility and met with Paige Woodard, Program Director and Eddie McCall, Program Manager. The purpose of the visit was to conduct a Required, two-year Annual Inspection of the facility. The facility was licensed on 12.23.22. LPAs utilized the CARE Tool to complete the inspection. LPAs conducted an inspection of the physical plant and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. The facility is on a large campus with many buildings. There are no clients sharing a bedroom in the dorm- like setting. The facility has 2 client bathrooms. All bathrooms were observed to be clean and fully functioning. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The facility has a properly fenced pool, and opportunities for clients to access sports equipment. LPAs observed the proper postings including facility license, complaint hotline, client personal rights, and emergency disaster plan. Smoke alarms, fire extinguishers and a first aid kit were observed to be current and within regulations. LPAs observed the kitchen and dining hall to be clean and well-stocked. There are 3 restaurant sized refrigerators and freezers with at least 10 days of perishable food and a months supply of non-perishable food on hand. LPAs observed client medications were stored in a locked file cabinet in the locked medical office. Client files are primarily electronic with paper files for clients locked in the Head of Service's office. The facility has no outstanding fees. ***Note: The inspection was not completed on 12.03.25. Inspection will be completed on 12.04.25.

met_with: Eddie McCall, Program Manager and Paige Woodard, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
The facility currently has 12 clients, with a licensed maximum capacity of 16. Staff to client ratio is 1 to 4. LPAs reviewed 10 staff files. Staff files had completed criminal record clearances, and all required initial and annual training. All First Aid and CPR certifications were up to date for staff. LPAs reviewed 5 client files. All clients have signed Admission Agreements on file. One of five clients did not have an initial NSP completed within 30 days. Needs and Services Plans detailed adequate supportive services that the facility offers to the clients. Clients were current on physical and dental exams. Review of 5 client files showed 4 of 5 clients were taking court ordered psychotropic medications and had current JV-220's on file. LPA interviewed 4 clients and 3 staff. Facility is issued a citation per Interim Licensing Standard Sections 87070(c)(1), Children's Records A signed copy of this LIC-809, LIC 809C, and 809D report were provided to Administrator An exit interview was conducted.


raw_content:
Narrative:
Staff interviews indicated that clients stay in this room until the treatment team deems the client is able to integrate back into the program. All youth interviewed indicated that the room is used to de-escalate but the youth weren't aware of a set time period to remain in the room. One staff member indicated that the youth can remain in the room for up to 5 days, however, they are allowed to leave the room to eat and sleep. Staff interviews were consistent that while youth were in the room, they are supervised by at least one member of staff and visited by members of their treatment team, given schoolwork, and taken outside for exercise. LPA reviewed records and there were no policies and procedures regarding the treatment room. LPA observed the treatment room to meet the definition of a Protective Separation Room, but no Protective Separation room was mentioned in the Program Statement. It was alleged that youth do not receive adequate food supply. Records reviewed showed facility's strict adherence to the National School Lunch food program. However, the National School lunch food program was not described or approved in the facility's approved Program Statement. One youth and one staff interviewed stated that there is not an adequate supply of food for the served population. One youth reported wanting more food, at which time their authorized representative mailed additional food supplements to the youth. Facility staff denied the youth from receiving or consuming the mailed food, without providing any written policies as to why the additional food was prohibited. Interviews were consistent that fruit is the only snack offered to the youth on weekends, which was not described in the Program Statement Two citations are being issued for violating Interim Licensing Standards (ILS) Section 87095.23 (a)(3) Protective Separation Room, Interim Licensing Standards (ILS) 87022 (e) Plan of Operation A signed copy of this LIC-9099 report, LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. Continued D Page Two youths stated that the calls were not private, with one youth indicating that a private call can be made upon request. All staff interviewed indicated that youth can request a private call and that staff will readily facilitate that opportunity. It was alleged that staff do not allow minors to get haircuts. All who were interviewed indicated that there is an opportunity provided twice per month for each youth to get a haircut. Interviews were inconsistent, however, with 2 youth and 2 staff indicating that certain types of haircuts are not permitted. No records were provided from the facility to support the assertion that a barber comes on site twice a month to do haircuts. The facility program statement did not detail policies regarding prohibiting certain types of haircuts. It was alleged that staff open youths' mail. Interviews were consistent that it is policy for staff to be present when youth open their mail to check for unallowed items but that this is done in front of the youth and that the staff do not read the youth's mail. Records reviewed showed that it is not policy for staff to read a youth's mail. There was an allegation that staff inappropriately restrained youth. All four youth interviewed, and all staff interviewed, corroborate that restraints are used appropriately and that there are policies in place to ensure they are done safely. LPA reviewed records and no incident reports documented any injuries caused by a restraint. Based on LPA's interviews which were conducted and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 01.05.26 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Thorn conducted the complaint investigation. LPA initiated the investigation with the facility on 10.17.25 and met with Paige Woodard, Program Director, and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed 4 youths, 8 staff, and 3 other confidential individuals. LPA reviewed records including LIC 500, client roster, staff contact information, Placing Agency contact information, Needs and Services Plan, case notes, and Child Family Team meeting notes for 1 client. Program Statement and Plan of Operations, as well as food services documents were also reviewed. It was alleged that staff isolate clients for extended periods of time. Interviews with staff were consistent that the treatment room was used as a space to help clients de-escalate when their behavior poses a safety risk to themselves or others. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YOSEMITE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 01/05/2026


raw_content:
Narrative:
It was alleged that the facility mismanaged client's records and did not send documents to the client's new placement in a timely matter upon discharge. Interviews with staff provided consistent statements regarding the policy and procedure when a client transfers from the facility. Three staff interviewed explained that the Release of Information had not been provided upon intake, as it was not found in the client's file. One staff member stated that they did receive the Release of Information document at the time of intake. This caused some initial miscommunication between staff; however, the release was obtained by the proper department within one day, and records reviewed indicated that the discharged documents were sent within two days to the new placement after the initial request. Based on LPA's interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on 01/12/26 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard Program Director (PM). LPA Tina Thorn conducted the complaint investigation. LPA Thorn initiated the investigation with the facility on 10/30/25 and met with Paige Woodard, Program Director. During the course of the investigation, LPA interviewed 6 staff, a county social worker, and one other confidential interview. LPA reviewed records from the facility including emails, Facility Intake Packet, Facility Program Statement and Facility Admissions Agreement. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Lyta Vue 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: YOSEMITE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 01/12/2026

met_with: Paige Woodard Program Director (PM)


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tina Thorn and Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility for the purpose of a case management inspection following a record review. LPA Thorn conducted the case management. LPA Thorn reviewed records from the facility including: staff scheduling rosters, staff contact information, criminal record clearances, and staff training log for the last three months. Additionally, LPA Thorn interviewed facility administrator and 8 staff. One staff member was working directly with clients without the required clearances. On 8/30/23, the staff member informed LPA Thorn they had been working for the past 7 months and knew they did not have a criminal record clearance on file. On 9/7/23, Administrator confirmed the staff did not have the required clearances, and the staff was pending an exemption. The staff was put on leave on 9/1/23. The facility is issued a citation per Title 22, Division 6, Chapter 6, Chapter 1, Article 3, Section 80019(e)(2): All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department An immediate civil penalty is being assessed, for $100 per day for a maximum of 5 days, resulting in a $500 civil penalty. A signed copy of this report, the LIC 809D and LIC 421BG were provided to the facility. Exit Interview was conducted and Appeal Rights were provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility for the purpose of a case management following a record review of drug tests conducted on a youth at the facility. Licensing Program Manager (LPM) Hillary Hall conducted the record review. LPM reviewed records from the facility indicating 1 youth was drug tested 3 times during the time period of 12/02/24-1/31/25. Of the 3 drug tests documented, all were done for reasons listed as return from home pass, or day pass. LPM reviewed the Program Statement for the facility and found no policies and procedures regarding drug testing youth. LPM contacted the youth's authorized representative who indicated they did authorize the youth to be drug tested, but were unaware the policies were not outlined in the facility Program Statement. LPM spoke with Program Director (PD) Paige Woodard on 2/4/2025 who indicated there were no known written or internal policies on drug testing the youth and the staff are not trained on drug testing. One citation is being issued per Title Division 6, Section 80022(k): Plan of Operation: (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. A signed copy of this 809 and 809D was provided to the facility.


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
It was alleged that staff did not report an incident in a timely manner. Records reviewed show that an incident on January 7, 2026, involving two minors and use of a restraint was reported to the department but was not reported to the authorized representative by facility staff. Records reviewed indicate that the representative had to request that the report be sent to them after hearing about the incident from the youth on January 13, 2026. Records also show that a 24-hour report for an incident that occurred on February 11, 2026, was not submitted to the department or authorized representative. All staff interviewed demonstrated knowledge of the facility's incident reporting policies. Based on LPA interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citation is being issued for violating Interim Licensing standards Section #87061(b) (3) A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 02.25.26 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard by phone and Columbus Bender in person. LPA Thorn conducted the complaint investigation. LPA Thorn initiated the investigation with the facility on 01.29.26 and met with Paige Woodard, Program Director, and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed one youth, three staff, and one other confidential interview. LPA reviewed records from the facility including prior complaint history, Serious Incident Reports, CFT notes and Needs and Service Plans for one youth and email correspondence. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YOSEMITE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 02/25/2026

met_with: Paige Woodard, Program Director and Columbus Bender, Compliance Manager

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
It was alleged that staff encouraged minors to attack another minor. Interviews with staff and minors were consistent that none of the staff encouraged minors in the program to attack another minor. Interviews with minors and staff also corroborate that the minor would make inappropriate comments to their peers to incite a physical altercation with them. Records reviewed indicated that this minor struggled with similar behavior issues and social functioning at previous placements. There was an allegation that staff spoke inappropriately towards a minor. One minor had conflicting information about one comment being made by a staff member. Six of six staff as well as three other confidential interviews corroborated that they are unaware of inappropriate comments made by a staff member. Nothing was found in a record review that indicates inappropriate comments were made to a minor by a staff member. Based on LPA's interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be Un-Substantiated. A signed copy of this LIC-9099 report and the LIC-9099C were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 02.25.26 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director and Columbus Bender, Compliance Manager. LPA Thorn conducted the complaint investigation. LPA Lyta Vue initiated the investigation with the facility on 12.18.25 and met with Eddie McCall, Program Manager and Paige Woodard, Program Director. During the course of the investigation, LPA interviewed four minors, one CASA worker, one county social worker, three facility staff and one other confidential interview. LPA reviewed records from the facility including Placement Roster, Prior Complaint History, Serious Incident Reports, CFT notes, Case Notes and Needs and Service Plans for one foster youth. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YOSEMITE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 02/25/2026


facility_name: YOUTH ACCEPTANCE 1

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Lourey Bartolome conducted a complaint inspection for the purpose of delivering the findings for the above complaint allegation. LPA spoke with Administrator Dorothy Shanklin. During the course of the investigation, Community Care Licensing (CCL) conducted interviews and review of documentation. Based on interviews and documentation, staff could of prevented inappropriate sexual interaction between youth and physical altercation between . Staff did not conduct the nightly checks and staff were not supervising the clients to prevent the above allegations from happening. Therefore the above allegations are substantiated. Type A: This poses an immediate health and safety risk to clients in care. Facility was cited for Title 22, Section 80078(a) Responsibility for Providing Care and Supervision SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Melanie Krage LICENSING EVALUATOR NAME: Lourey Bartolome 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239

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

met_with: Dorothy Shanklin


raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Lisa Slusher conducted a complaint inspection for the purpose of delivering the findings for the above complaint allegations. LPA spoke with Administrator Dorothy Shanklin. During the course of the investigation, Community Care Licensing (CCL) conducted interviews and review of documentation. Based on interviews and documentation, clients have on multiple occasions been picked up late from school. On at least one occasion, client's journal was read by staff and pages were torn out. Clients have been brought religious pamphlets to read. During an incident in August of 2021, C2 (See LIC 811) pushed a table, hitting S1 in the chest. S1 became upset and threatened to break the nose of C2. Interviews conducted note that youth were not allowed a cell phone until level 4. There are no notations regarding cell phones in needs and services plans. Type A: This poses an immediate health and safety risk to clients in care. Facility was cited for Title 22, Section 80078(a) Responsibility for Providing Care and Supervision and 87072(c) Personal Rights. A civil penalty is assessed on this date. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239

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


raw_content:
Investigation Findings:
13On December 3, Liicensing Program Analyst (LPA) Lisa Slusher conducted a follow-up complaint inspection at Youth Accep. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Slusher interviewed staff, clients and reviewed pertinent documents. Based on interviews conducted and information gathered, there were some discrepancies found. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report and appeal rights were emailed to facility Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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


summary: Complaint Investigation - Substantiated - 2 deficiencies - 1 allegation

raw_content:
Narrative:
Administrator, based on interviews and admission, has not been present at the facility a minimum of 20 hours per week. Staff person #1 (See LIC 811) did not have a fingerprint clearance prior to working with youth in the facility. Type A: This poses an immediate health and safety risk to clients in care. Type B: This poses a potential threat to the health, safety or personal rights of clients in care. Based on the LPA's observations, interviews, records review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be substantiated. A copy of the report and Appeal Rights was provided to the agency. Facility was cited for The Interim Licensing Standard (ILS) Chapter 7. Version 3. Articles 1 through 10. The Agency is being cited for violations of Section 87072(c) Personal Rights, 87064 (a) Administrator Qualifications, 87078(b) Responsibility for Providing Care and Supervision, 87095.24(a) Runaway Plan, 87065.5(a) Direct Care Ratios, 80019(c) Criminal Record Clearance.

Investigation Findings:
13Licensing Program Analysts (LPAs) Lisa Slusher and Tamara Melikian conducted a follow-up complaint inspection with the above facility. Analysts met with Administrator Dorothy Shanklin. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, Community Care Licensing (CCL) conducted interviews with facility staff and foster youth and other interested parties as well as conducted a review of records including incident reports and police reports. The information obtained during the investigation substantiates the allegations. A review of the staff schedule notes only one staff person between 7:00 and 8:00am and only one staff member between 9:00 and 10:00 pm consistently. Interviews and staff schedule indicate other times when the facility has not met appropriate ratios. A review of needs and services plans for C1, C3 and C5 indicates a need for 1: Staffing. Additionally, several incident reports indicate as follow up that the facility is adding 1:1 staffing. The youth served by the facility have a high incident of suicidal ideations and attempts. Facility is not meeting the needs of these youth. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239

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

Deficiencies:
87065.5: (1) 	During the hours of 7 am to 10 pm, there shall be one awake and on duty direct care staff for every three children, or fraction thereof, present, at a minimum.1
2
3
4
5
6
7Per Administrator, Schedules have been updated to reflect appropriate ratios. Schedule provided to LPA on this date.
8
9
10
11
12
13
14
87095.241: (1)	Runaway child(ren).

title: Direct Care Staff/Child Ratios	(a) 	In a facility with a licensed capacity of six or fewer children, there shall be coverage by direct care staff as follows

title:
2
3
4
5
6
787095.24	Runaway Plan
(a)	The licensee must develop, maintain and, when necessary, execute a written runaway plan. The runaway plan must describe how staff will respond to the following

description: (1)	Runaway child(ren).


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Investigation Findings:
13On the above date, LPAs (Licensing Program Analysts) Lisa Slusher and Tamara Melikian met with Administrator Dorothy Shanklin for the purpose of delivering the findings for the above noted complaint. During the investigation, LPA reviewed placement and file documents, receipts and conducted interviews. C1 was discharged from the facility in May of A P-EBT card was mailed to the facility in early August of 2021 in the amount of $1234.00. Receipts and other records confirm that the EBT card was utilized to pay for facility groceries in September of 2021, December of 2021, January of 2022 and February of 2022. The facility utilized more than $500 of the P-EBT funds. P-EBT funds are for the use of the recipient only. The facility failed to return the card to C1 and instead comingled client's funds with facility funds. Based on the evidence above, the allegation is Substantiated. A citation is issued for CCR, Title 22, Division 6 section 80026(e). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239


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Investigation Findings:
13On the above date, LPAs (Licensing Program Analysts) Lisa Slusher and Tamara Melikian met with Administrator Dorothy Shanklin for the purpose of delivering the findings for the above noted complaint. During the investigation, LPA reviewed placement and file documents, and conducted interviews and reviewed other documentation. On or about 3/1/22 the iPad utilized by C1 for Interpretation was confiscated while doing room searches. This poses a threat to client health and safety. The facility is cited on this date for a violation of CCR title 22, Division STRTP ILS section 87072(c). This section was previously cited on 12/21/21 and 3/16/22. A civil penalty is also assessed on this date. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, LPAs (Licensing Program Analysts) Lisa Slusher and Tamara Melikian met with Administrator Dorothy Shanklin for the purpose of delivering the findings for the above noted complaint. During the investigation, LPA reviewed placement and file documents, and conducted interviews. C1 has maintained a relationship with a former staff person. No documentation indicates that the county has prohibited C1 from contacting this individual, and contact is not limited in a needs and services plan. Based on the evidence above, the allegation is Substantiated. A citation is issued for CCR, Title 22, Division STRTP ILS 87072(c)(8). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239

met_with: Dorothy Shanklin, Jeffrey Johnson


raw_content:
Investigation Findings:
13Licensing Program Analysts (LPAs) Lisa Slusher and Tamara Melikian conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Dorothy Shanklin. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Slusher conducted interviews with clients, staff, and others. The interviews and document review indicated that although the individual has been present in the agency office and had incidental client contact, it is not clear that the contact rises to a standard of requiring a criminal record clearance. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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:
13Licensing Program Analysts (LPAs) Lisa Slusher and Tamara Melikian conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Dorothy Shanklin. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Slusher conducted interviews with clients, staff, and others. LPA reviewed incident reports. The interviews and document review indicated conflicting information about the state of the youth when returning from runaway. The interviews regarding the staff person indicated conflicting information about when the staff person tested positive and whether the staff had tested negative prior to returning to work. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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:
13Licensing Program Analysts (LPAs) Lisa Slusher and Lidia Tinoco conducted a follow-up complaint inspection with the above facility. Analysts met with Administrator Dorothy Shanklin. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, Community Care Licensing (CCL) conducted interviews as well as conducted a review of records including incident reports and police reports. The information obtained during the investigation substantiates the allegations. The content of the interviews and reports substantiates that C1, who was pregnant had to wait to receive medical care when she was complaining of an upset stomach following a runaway incident. During the same incident on 4/9/22 client injured her hand when staff member shut the door to block C1 from leaving. Additionally, 2 youth had to accompany C2 to the emergency room on 4/17/22 because additional staff were not available. Citations are issued on this date for ILS 87272(c) and CCR title 22 section 80078(a) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 CCLD Regional Office, E SHAW AVE FACILITY NAME: YOUTH ACCEPTANCE 1FACILITY NUMBER: 107203239


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Corina Carrillo conducted a Case Management Inspection on July 7, 2021 at 9:00am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code Section 1538.7. 4 out of Direct Care Staff and 5 out of 5 youth files as identified on the LIC Confidential Names dated July 7, 2021, were reviewed. 2 out of the Direct Care Staff and 4 out of 5 youth were also interviewed. The Plan of Operation including policies and procedures were reviewed. A copy of this report was discussed and provided to Dorothy Shanklin, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, an unannounced annual inspection begins at the corporate office for Youth Acceptance 1. On this date, LPA (Licensing Program Analyst) observed employee files and training records through extended reach. All staff have appropriate fingerprint clearance. No deficiencies noted in areas observed.

met_with: Christopher Toledo


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lisa Slusher travelled to the facility listed above to Continue the annual inspection begun on 9/17/21. The facility listed above is accredited through CARF and has current Mental Health Program Approval through Fresno County. The following were observed upon inspection of the physical plant: 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. Observed medication logs and discussed procedures for psychotropic medications. 5. First aid kit complete with appropriate manual observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 4 bedrooms, double occupancy, located on the second level. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Supply of two days of perishable foods and a week of nonperishable foods observed upon inspection. 10. Weekly menu posted and accessible to clients. 11.Dining room equipped with large table and chairs accommodating of all clients. 12.Facility has two full restrooms in the house for client use, one half-bath (toilet only) all are operable. 13.Appropriate forms posted in view of facility clients. 14.No firearms or weapons are allowed in the facility. The following items were discussed and reviewed by LPA during Inspection 1. LIC Reviewed to ensure appropriate staffing ratios, including Administrator, Social Work personnel, and Direct Care staff. 2. Administrator Dorothy Shanklin is present on-site a minimum of 20 hours per week. 3. Personnel files reviewed prior to today's inspection to ensure staff meet regulatory requirements. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are retained at the office at N. Sixth Street, Suite 171-172, Fresno 93710. 4. Client files reviewed on this date. Client and staff interviews conducted. No deficiencies noted in areas observed.

met_with: Dorothy Shanklin, Dorothy McDonell


summary: Facility Evaluation

raw_content:
Narrative:
On this date, a case management inspection is conducted at the Imagine You office in Fresno, CA. Discussed facility program statement and mental health program. Discussed regulation updates and facility processes. Visit concluded.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, a case management inspection is conducted by LPA (Licensing Program Analyst) Lisa Slusher. Met with Administrator Dorothy Shanklin. The purpose of this inspection is to follow up on issues that were uncovered during the course of an investigation. A Technical Advisory is issued for the following areas: The current point/discipline system does not meet regulatory requirements for trauma informed discipline procedures, nor does the written plan account for developmental differences, historical trauma or client-specific differences between youth in care, The facility is to submit updates by 1/21/22. A review of the facility's food costs for October of 2021 as well as interviews with facility personnel, youth and others indicates the facility's budget for food is below the USDA's recommendations. Interviews also indicate dissatisfaction with the quality and quantity of food served with meals. The facility is advised to connect with youth and current recommendations. A review of Volunteer Program information as well as personnel , client and other interviews indicates that The program implemented by the facility is not well-understood by personnel or clients. There is a discrepancy in information about how many hours are required, whether partial hours count, and whether behavioral issues impact client payment. The facility is encouraged to detail these items to make the program and details clear for all involved.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, a case management inspection is conducted by LPAs Lisa Slusher and Vanessa Galvan. Discussed qualifications of Administrator. On this date, LPA provided a Technical Assistance advisory note regarding administrator qualifications and duties.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, an office meeting is held at the CCLD office at E. Shaw Ave., Fresno. Licensing Program Analyst Lisa Slusher, Licensing Program Manager Lourey Bartolome and Regional Manager Nelson Martinez were present for the Department. Imagine you representatives Dorothy Shanklin, Executive Director and Administrator) and Jeffrey Johnson, Chief Financial Officer and Emergency Intervention (CPI) instructor. The purpose of this meeting is to discuss the Non-Renewal of the Mental Health contract and Mental Health Program approval by Fresno County Department of Behavioral Health. The facility's MHPA will expire on June 30, 2022 and will not be renewed by Fresno County DBH. The facility is to submit a closure plan as described in PIN 18-03 by 5/30, regardless of the Licensee's plan for the facility. Additionally, the licensee, including board approval is to submit a plan for the future of the facility, describing how the licensee intends to move forward.

visit_type: Renewal


summary: Facility Evaluation

raw_content:
Narrative:
On this date, LPAs (Licensing Program Analysts) Lisa Slusher and Vanessa Galvan conducted a case management inspection at the corporate office for Youth Acceptance 1. The purpose of this inspection is to address issues from file reviews and physical plant inspection. On 1/26/ LPAs observed and photographed small pieces of glass in the street in front of the facility. Reports by staff indicate this is left over from an incident on 1/13/22 where the window of a staff's vehicle was broken by facility clients. The pieces of glass, while small, are large enough for youth to utilize the pieces for self harm. A citation is issued on this date for CCR title 22, Division 6 section 80087(a)


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 03/16/2022, Licensing Program Analysts (LPAs) Lisa Slusher and Tamara Melikian conducted a case management inspection for the Youth Acceptance 1 facility. Met at the corporate office of Youth Acceptance 1 by Administrator Dorothy Shanklin. The purpose of the inspection is to issue a deficiency for personnel not having appropriate Emergency Intervention Training. The purpose of the inspection is to also issue a deficiency for Mental Health Rehabilitation Specialists (MHRS) being used as direct care staff impeding their duties as an MHRS. Deficiencies on the attached page.

Deficiencies:
87065.5(e): (1) Doing so does not prevent the individual from conducting the specific duties for which they are is employed.(2)	Appropriate care and supervision is maintained.

title:
1
2
3
4
5
6
787065.5(e) Direct Care Staff/Child Ratios. (e) A facility may count its certified administrator, facility manager, or a mental health rehabilitation specialist, as defined by the Department of Healthcare Services, towards its staff to children ratio, provided


summary: Facility Evaluation

raw_content:
Narrative:
On May 5, 2022, Licensing Program Analysts (LPAs) Tamara Melikian and Lisa Slusher conducted an unannounced case management inspection to issue deficiencies to the above facility. Met by Administrator Dorothy Shanklin. Reportable incidents occurred on April 9, 2022 involving C1, C2 and C3 (see LIC811 dated 05/05/2022) that were not reported to Community Care Licensing. In addition, an incident occurred on April 13, 2022 involving an emergency intervention technique with C3 (see LIC811 dated 05/05/2022). Incident report received by Community Care Licensing states that C3 needed to be manually restrained because C3 and the staff were on the stairs as C3 was trying to push through the staff to go upstairs. The incident report states that the "Manual restraint was needed due to client and staff being on the stairs in an area where the risk of injury would be more likely and result in greater severity". The report does not indicate that the client exhibited assaultive or aggressive behavior presenting an immediate danger to themselves or others. Deficiencies on the attached page. A copy of this report was given to Administrator Dorothy Shanklin.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On May 5, 2022, Licensing Program Analysts (LPAs) Tamara Melikian and Lisa Slusher conducted an unannounced case management inspection. Met by Administrator Dorothy Shanklin. The purpose of the inspection is to issue a deficiency for an incident that occurred regarding cash resources for former client C1 (see LIC811 dated 05/05/2022). The facility utilized a Pandemic EBT card issued to C1 to pay for facility groceries. The client left the facility in May of 2021. The card was received by the facility in August of 2021 and utilized in September of 2021, December of 2021, January of 2022 and February of 2022. PEBT cards are issued to the recipient and are not to be utilized by other individuals. Deficiencies on the attached page. A copy of this report is given to Administrator Dorothy Shanklin on this date.

Deficiencies:
80064(a): (3)	Knowledge of and ability to comply with applicable law and regulation.

title:
1
2
3
4
5
6
780064(a) Admnistrator Qualifications. (a)	The administrator shall have the following qualifications


summary: Facility Evaluation

raw_content:
Narrative:
On June 2, 2022, Licensing Program Analysts (LPAs) Lisa Slusher and Tamara Melikian conducted a case management inspection with the above facility. Met by Executive Director Dorothy Shanklin. The purpose of the case management is to issue a deficiency for the facility not having mental health program approval effective May 17, 2022. In addition, the facility will not have site certification or a contract effective June 30, 2022. Deficiency on the attached page. A copy of this report is given to Executive Director Dorothy Shanklin on this date.

met_with: Dorothy Shanklin, Jeff Johnson