facility_name: MAYWRIGHT GROUP HOME

raw_content:
Narrative:
not receiving therapeutic services as required, and C1 is not attending school regularly. Specifically, it was reported the STRTP lacks supervision for clients as clients are allowed to stay out past PM. It was also reported C1 is not receiving therapeutic services due to therapist availability issues and facility never notified C1's CSW of this. It was also reported that C1 did not attend school for a month. Several witnesses corroborate that therapeutic services were minimized due to service providers having COVID19 and also STRTP clients declining services. Facility provided LPA verification of mental health treatment service logs which demonstrate weekly services provided to C1 or C1 declining services. Staff confirmed therapist was out with COVID19 on occasion but provided LPA information about staff-led "groups" that were provided to clients in the meanwhile. Finally, staff confirmed C1 was not in school for almost three months, however, facility provided emails from school district corroborating efforts being made to enroll C1 in school, however, the facility had to wait for a school to accept C1 as several had denied enrollment. Several confidential interviews corroborate the allegations are "not true" and corroborate that staff are always supervising clients in the home and some clients are approved by their county social workers to take community walks that can last anywhere from 15 minutes to 1 hour depending on the client. Facility confirms the clients are not generally out past PM, but on occasion, clients may return late. Facility provided LPA with corroborating documentation of this information. Facility took action in each of the allegations reported and followed standard protocol. While a witness maintains these allegations occurred, the majority of all confidential interviews corroborate the information provided by facility. Based on interviews conducted and information obtained, the allegations that staff do not provide adequate supervision, C1 is not receiving therapeutic services as required, and C1 is not attending school regularly, may have occurred, however, they are not supported or proven by evidence. The allegations are, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to Mr. Clifford Moss for signature. Signed report will be placed in facility file.

Investigation Findings:
13On April 29, 2022, at 8: AM, Licensing Program Analyst (LPA) Carmen Escobar made contact at the facility with Short-Term Residential Therapy Program (STRTP) acting facility manager (FM) Clifford Moss. LPA Escobar conducted a facility risk assessment interview with FM and proceeded to issue the investigative findings for the above allegations. During the investigation, LPA requested documents from client 1 (C1's), client 2 (C2's), and client 3 (C3's) files including placement agreements, copy of C1's most current needs and service plan, special incident reports involving C1, C2, and C3, verification of mental health services for clients, and visitation documents for clients. LPA also obtained a copy of the facility's client roster. LPA Escobar conducted interviews with the FA, staff 1 (S1), staff 2 (S2), C1, C2, and C3, C1 and C2's county social worker (CSW) and another involved party. LPA Escobar completed the initial ten-day inspection to initiate the complaint with the facility on 10/21/21 at 2: PM, no health or safety concerns were observed. It was alleged that on or around 10/15/21 staff do not provide adequate supervision, C1 is UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Facility Manager-Clifford Moss


state: CA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
before being enrolled in school, C1 is constantly late to school, and facility is non-responsive to school regarding C1. Specifically, it was reported that C1 is late for school almost on a daily basis. When addressed with C1, it was reported C1 is late to school due to staff being late each morning during shift change. Additionally, C1 was at the facility for over a month before being enrolled in school. Staff confirmed C1 was not in school for about a month, however, facility provided emails from school district corroborating efforts being made to enroll C1 in school. The facility had to wait for a school to accept C1 as several had denied enrollment. Finally, it was also reported a confidential witness has reached out to the facility "time after time" regarding C1's school attendance and school concerns and the facility has not called back or made any effort to communicate with involved party. While a witness maintains this occurs, all other witnesses corroborate clients, including C1, are not late to school because of staff, rather, are late because clients refuse to wake up for school. Several witnesses corroborate staff will provide verbal direction for clients to get up, however, clients refused to get up for school. Facility provided LPA with corroborating documentation of this information in the daily log. Finally, while a witness maintains staff has made no effort to be in communication with C1's school, the majority of all confidential interviews corroborate the facility took a few weeks to get into the habit of being in constant communication with schools, however, once facility began with more communication, the facility has stayed on top of everything and make a constant effort to update schools and county social workers if anything comes up or needs to be addressed regarding clients. Several confidential witnesses confirm the facility is "doing what it needs to do" for clients in their care. The confidential witnesses corroborate they do not like to get up for school and neither did C1 at the time; this always made clients late to school. Other witnesses maintain the facility did not communicate well at first, but within a few weeks, had everything together and have been doing a great job since then regarding client communication with both schools and CSWs. Based on interviews conducted and information obtained, the allegations that C1 was at facility for an extended period of time before being enrolled in school, C1 is constantly late to school, and facility is non-responsive to school regarding C1, may have occurred, however, they are not supported or proven by evidence. The allegations are, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to Mr.Clifford Moss for signature. Signed report will be placed in facility file.

Investigation Findings:
13On April 29, 2022, at 9: AM, Licensing Program Analyst (LPA) Carmen Escobar made contact at the facility with Short-Term Residential Therapy Program (STRTP) facility manager (FM) Clifford Moss. LPA Escobar conducted a facility risk assessment interview with FM and proceeded to issue the investigative findings for the above allegations. During the investigation, LPA requested documents from client 1 (C1's), client 2 (C2's), and client 3 (C3's) files including placement agreements, copy of C1's most current needs and service plan, special incident reports involving C1, C2, and C3, documentation of communication with client's schools, and communication records for clients. LPA also obtained a copy of the facility's client roster and school attendance records for clients. LPA Escobar conducted interviews with the FA, staff 1 (S1), staff 2 (S2), C1, C2, and C3, C1 and C2's county social worker (CSW) and another involved party. LPA Escobar completed the initial ten-day inspection to initiate the complaint with the facility on 10/21/21 at 3: PM, no health or safety concerns were observed. It was alleged that on or around 10/20/ C1 was at facility for an extended period of time UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

report_type: Complaint Investigation

met_with: Facility Manager (FM) Clifford Moss

complaint_status: unsubstantiated


raw_content:
Narrative:
During investigation confidential interviews reported that staff make multiple attempts to wake up clients for school each morning however, there are times when clients refuse to attend school. Confidential interviews also stated that staff report school refusals on incident reports and when needed staff conduct meetings with the client's county social worker to discuss alternative options. Other confidential interviews reported that clients do not attend school for different reasons and stated that staff are okay with it. During LPA's visit to the STRTP two out three clients were not at school as required and clients reasons for missing school were not clear. Other Confidential interviews stated that school truancies result in termination of placement for not following program expectations. LPA received inconsistent information regarding the allegation. Based on confidential interviews, the allegation that staff do not ensure that clients attend school on a regular basis, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Philip Roberts

Investigation Findings:
13On March 14, 2023, at 10: AM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Maywright Short Term Residential Therapeutic Program (STRTP) to deliver the findings of the above stated allegations. LPA was met by Facility Manager, Philip Roberts. LPA Carmen Escobar conducted an inspection of the facility on September 8, 2022, at 4: PM and no immediate deficiencies were observed. Additionally, LPA Escobar collected pertinent documents from the STRTP's staff and client files. LPA Urena interviewed three of five clients (C1, C2, C3,) and two staff members, Facility Manager (FM) and Case Manager (CM). Two clients involved (C4, C5) could not be reached for an interview. On August 31, 2022, Community Care Licensing (CCL) received a complaint alleging that staff do not ensure that residents attend school on a regular basis. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 03/14/2023

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

met_with: Facility Manager, Philip Roberts


raw_content:
Narrative:
During investigation confidential interviews reported that C1 returned to the STRTP from an absent without leave (AWOL) and was under the influence. Confidential interviews further stated that C2 did hit C1 while in care resulting in injuries despite staff efforts to stop the physical altercation. Another confidential interview denied that C1 was involved in an altercation with C2 but stated that C1 was hit, and injuries were sustained during an altercation involving an unknown client. Confidential interview further stated that C1 refused medical attention for the injuries sustained. Other confidential interviews reported that C1 was taken out of the STRTP by law enforcement to the hospital following the altercation with C2. An incident report dated September 3, 2022, was obtained which confirmed that an altercation did occur between C1 and C2 which resulted in C1's injuries. LPA received inconsistent information regarding whether or not staff present did enough to prevent C1 from being hit while in care. Based on confidential interviews, and record review the allegation that staff did not prevent a minor from hitting another minor while in care, and that staff did not seek timely medical attention for a minor, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Philip Roberts.

Investigation Findings:
13On March 14, 2023, at 11: AM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Maywright Short Term Residential Therapeutic Program (STRTP) to deliver the findings of the above stated allegations. LPA was met by Facility Manager, Philip Roberts. LPA Carmen Escobar conducted an inspection of the facility on September 8, 2022, at 4: PM and no immediate deficiencies were observed. Additionally, LPA Escobar collected pertinent documents from the STRTP's program staff and client files. LPA Urena interviewed three of five clients (C1, C2, C3,) and two staff members, Facility Manager (FM) and Case Manager (CM). Two clients involved (C4, C5) and C1's County Social Worker could not be reached for an interview. On September 7, 2022, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent a minor from hitting another minor while in care, and that staff did not seek timely medical attention for a minor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 03/14/2023

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


raw_content:
Narrative:
staff. Confidential interviews stated that contraband was removed by staff before FM returned tin box to C1. While other confidential information received by Licensing Office stated that allegations had occurred, and that contraband was not removed from tin box before being returned to C1. There were no other known witnesses to these allegations. Based on interviews and confidential information obtained during the course of this investigation, the allegation that staff are providing contraband to minors, more specifically that staff provided a vape pen and a lighter to Child # 1 (C1), may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Facility Manager, Robert Phillips to discuss the investigative findings for the above stated allegations. LPAs Carmen Escobar and Cynthia Urena conducted an inspection of the Facility on November 22, 2022, at 9: AM and on June 02, 2023, at 10: AM. No immediate hazards were observed. LPA Urena interviewed three of four foster children (C2, C3 & C4), Facility Manager (FM), Facility Administrator (ADM), as well as reviewed facility and client records. LPAs Urena and Mena were unable to interview Child # 1 (C1) regarding allegations due to their current whereabouts being unknown. Community Care Licensing received information on November 15, 2022, alleging that staff are providing contraband to minors, more specifically that staff provided a vape pen and a lighter to Child # 1 (C1). Information obtained in confidential interviews did not corroborate the allegation with a preponderance of evidence. LPA Urena obtained conflicting information during interviews. Confidential interviews denied allegations that Facility Manager (FM) or any other staff have ever provided clients with any vape pens, drugs, or contraband. According to confidential information, incident mentioned in the complaint allegation occurred when tin box containing a vape pen and a lighter belonging to C1 were confiscated by UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 10/06/2023

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

met_with: Phillip Roberts


raw_content:
Narrative:
Regarding the allegation of staff is giving illegal substances to minors in care, a confidential witness reported that staff was providing illegal substances (speed and marijuana) to minors in care. Multiple confidential witnesses denied that staff would give minors in care illegal substances. Details from confidential interviews stated that they had not witnessed staff giving illegal substances to minors in care. Confidential interviews stated that staff would confiscate illegal substances from minors in care when found. Further details gathered stated that staff would check minors in care for illegal substances at the facility, specifically, when returning from being absent from care. Additional details from confidential interviews stated that minors in care were able to obtain illegal substances, however, it was not from facility staff. Regarding the allegation that minors are doing drugs at the facility, a confidential witness reported that minors are doing drugs at the facility. Confidential interviews denied that minors in care are doing drugs at the facility. Details gathered from confidential interviews stated that minors in care are aware of the facility being drug free and staff had procedures in place to ensure that minors in care were not doing drugs at the facility. Additional details from confidential interviews stated that they had witnessed minors in care doing drugs at the facility. If a minor in care was caught doing drugs at the facility, staff would follow reporting procedures and 14-day removal polices to address these behaviors. Other confidential interviews stated that if minors in care did do drugs, they would do them off of facility grounds. LPA received inconsistent information regarding the above allegations. Based on record review and confidential interviews, the allegations that staff is giving illegal substances to minors in care and minors are doing drugs at the facility, may or may not have occurred; However, it is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted, appeal rights were discussed and provided. A copy of the report was given to Philip Roberts, House Manager.

Investigation Findings:
13On January 26, 2024 at 4:18 pm Licensing Program Analyst (LPA), Emina Preciado, arrived at Maywright Group Home, Short Term Residential Therapeutic Program (STRTP) and met with Philip Roberts, House Manager, to deliver findings on the above mentioned allegations. LPA Belinda Torres conducted a health and safety assessment of the facility on January 20, 2023 and no immediate deficiencies were observed. The investigation included interviews with two staff (S1 and S2), three out six foster youth (C1, C4, and C6). Three of six foster youth are (C2, C3, and C5) are no longer foster care dependents or their whereabouts are unknown. After multiple attempts, LPA was unable to interview them as part of this investigation. In addition, county and facility records were reviewed. On January 19, 2023, Community Care Licensing (CCL) received two allegations that staff is giving illegal substances to minors in care and minors are doing drugs at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Emina Preciado 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 01/26/2024

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

met_with: Philip Roberts, House Manager


raw_content:
Narrative:
A confidential interview reported that staff did not take C1's clothes to the Laundromat and did not allow C1 to go to the laundry to wash their (C1's) clothing. Other confidential interviews provided conflicting information and reported that C1 often refused to go to the Laundromat and would not allow staff to take C1's clothes for washing. Confidential interviews denied that C1 or other clients were made to wear dirty clothes and reported that C1 did have clean clothes. However, C1 did not always do their (C1's) laundry and mixed up their (C1's) clean and soiled clothes. In addition, a confidential interview reported that C1's appearance was neat, and C1's clothing was clean and appropriate for the weather. Furthermore, a confidential interview and documentation reported the washing machine was replaced in September 2023, and LPA observed a working washing machine and dryer during the health and safety inspection. Based on inconsistent confidential interviews and documentation, the allegation that staff are not ensuring that minor(s) (C1) have clean clothing while in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report, and appeal rights were explained and given to Facility Manager, Philip Roberts.

Investigation Findings:
13On March 6, 2024, at 8: AM, Licensing Program Analyst (LPA) Jessica Peete conducted an unannounced visit to Maywright Short Term Residential Therapeutic Program (STRTP)) to deliver the investigative findings for the allegation listed above. LPA obtained documents pertinent to the investigation and interviewed Clients (C1-C5), STRTP staff (S1-S5), and County Social Workers (CSW1 and CSW2). On 12/26/2023, Community Care Licensing received an allegation that staff is not ensuring that minor(s) (C1) have clean clothing while in care. It was alleged that the STRTP did not have a washing machine, and C1 could not wash their clothes. Multiple confidential interviews reported that the washing machine at the STRTP was non-operational for a few weeks. Prior to the washing machine breaking, confidential interviews reported clients washed clothes every week or as often as needed. Confidential interviews reported while waiting for the washing machine to be repaired, staff took the clients to the laundromat no less than once a week. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jessica M Peete 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 03/06/2024

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The incident report also reported that C1 had no adverse side effects from the medication. Confidential interviews reported that the STRTP's medication protocol requires staff to give clients medication in the staff office. Before giving the medication, staff check the labels to ensure they have the right medication and verify the client's identity. Staff will then place the medicine in a cup to be given to the client and complete the Psychotropic Medication Administration Record (MAR). Corroborating confidential interviews admitted the incident took place and reported that S2 did not follow the STRTP's medication procedure. A Confidential interview reported that S2 failed to follow the procedure because they (S2) felt "rushed" and gave C1 the medication in the bedroom without verifying the medication was being given to the correct client. During the health and safety inspection, LPA was provided with C1's MAR, and the medication error was documented. However, the staff signature and initials were missing. LPA also observed all medications were centrally stored inside a locked box in the living room closet. All medication was observed to be in their original bottle, with labels unaltered, and stored separately in zip lock bags. Additional documentation provided to LPA shows staff received retraining on medication management on 02/13/2024. Furthermore, a confidential interview reported that S2 has not administered medication since the incident, and the staff was instructed to give the client medications in the staff office, according to the STRTP's standard procedure. Based on confidential interviews and a review of pertinent documents, the allegation that staff (S2) mismanaged a child's (C1) medication is substantiated. The preponderance of evidence standard has been met. The STRTP is cited with a violation of Interim Licensing Standards (ILS) 87075(a)(c) Health Related Services (a) In addition to California Code of Regulations, Title 22, Section 80075, the following shall apply (c) Psychotropic medications shall be used only in accordance with the written directions of the physician prescribing the medication... The STRTP was issued a LIC Technical Violation (TV) regarding Interim Licensing Standards 87070(b)(14)(h) Children's Records (b) The following information regarding the child shall be obtained and maintained in the child's record (14) A separate log for each psychotropic medication prescribed to a child documenting all of the following (h) Staff initials for each time a psychotropic medication is taken by a child... An exit interview was conducted. A copy of this report and appeal rights were explained and given to Facility Manager, Philip Roberts

Investigation Findings:
13On March 19, 2024, at 10: AM, Licensing Program Analyst (LPA) Jessica Peete conducted an unannounced visit to Maywright Short Term Residential Therapeutic Program (STRTP) to deliver the investigative findings for the allegation listed above. LPA obtained documents pertinent to the investigation and interviewed Clients (C1 and C2), STRTP staff (S1 and S2), and the County Social Worker (CSW). LPA attempted to interview C3, C4, and C5 but was unsuccessful because C3s whereabouts were unknown, and clients (C4 and C5) declined to be interviewed. On 01/23/2024, Community Care Licensing received an allegation that staff (S2) mismanaged a child's (C1) medication. It was alleged there was a medication error, and S2 accidentally administered C3's medication to C1. The incident report provided to the Department on 01/19/2024 confirmed that C1 was mistakenly given the wrong medication.The incident report states that S2 immediately reported the mistake to S1, and C1 received medical attention. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jessica M Peete 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: 360911229

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

met_with: Philip Roberts, Facility Manager

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
observed two laundry baskets and a dresser that reportedly belongs to C1 and five pairs of shoes in C1's closet. Confidential interviews and record review provided conflicting statements regarding the clothing and shoes fitting C1. Confidential interviews and record review provided conflicting statements of how often C1 is provided with new clothes and new shoes in order to ensure proper fit for C1. Based on record review, LPA observation, and confidential interviews the allegations alleging staff do not ensure that minor's (C1) clothing needs are met while in care and staff do not ensure that minor (C1) has appropriate shoes while in care may have occurred, however they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Maywright Group Home Administrator, Jerome Jordan.

Investigation Findings:
13On June 14, 2024 at 11:45AM Licensing Program Analyst (LPA), Nicole Strickland met with Maywright Group Home Administrator, Jerome Jordan, to deliver the findings for the above stated allegations. A Health and safety inspection of the facility was conducted on May 3, 2024, and no immediate hazards were observed. The investigation included interviews with two foster children [Child #1 (C1) and Child #2 (C2)], two staff [Faciilty Manager (FM) and Staff #1 (S1)], and one county social worker. In addition, county records, facility records, and photographs were reviewed. On April 26, 2024, Community Care Licensing (CCL) received two allegations alleging staff do not ensure that minor's (C1) clothing needs are met while in care and staff do not ensure that minor (C1) has appropriate shoes while in care. Specifically, it was reported C1 was observed wearing a pair of pants with broken elastic and pair of flip flops which were allegedly C1's only pair of shoes. On 5/3/2024, LPA UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 06/14/2024

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

met_with: Administrator, Jerome Jordan


raw_content:
Narrative:
Confidential interviews revealed that C1 was being bullied by C2 in the garage and was threatened not to tell anybody about it. Additionally, confidential interviews revealed that they are not aware of any bullying until C1 was removed from the group home. Furthermore, confidential interviews revealed conflicting statements and there were no witnesses to the alleged incident. Based on confidential interviews, the allegation that due to lack of supervision resulting in C1 being bullied by C2 while in care, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Maywright Group Home Short Term Residential Therapeutic Program (STRTP), Terry Torsu, Youth Counselor.

Investigation Findings:
13On December 04, 2024 at 10: AM, Licensing Program Analyst (LPA) Sarah Lo met with Terry Torsu, Youth Counselor, to deliver the finding for the above complaint allegation at Maywright Group Home Short Term Residential Therapeutic Program (STRTP). On 08/22/24, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with two staff (S1, S2), five clients (C1, C2, C3, C4 and C5), and County Social Worker (CSW). Clients' Needs and Services Plans were reviewed. On August 20, 2024, Community Care Licensing received an allegation that due to lack of supervision resulting in minor (C1) being bullied by another minor (C2) while in care. Specifically, it was reported that C1 does not feel safe at the group home and was being bullied by C2. (Continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 12/04/2024

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

met_with: Terry Torsu, Youth Counselor


raw_content:
Narrative:
Confidential interviews revealed conflicting statements that S2 called C3 names while S2 was driving C3 to school alone. Other, confidential interviews denied the allegation and stated they never called C3 derogatory names. Furthermore, there were no witnesses to the alleged incident. Based on confidential interviews, the allegation that staff do not treat C3 with respect, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Maywright Group Home Short Term Residential Therapeutic Program (STRTP), Terry Torsu, Youth Counselor.

Investigation Findings:
13On December 04, 2024 at 11: AM, Licensing Program Analyst (LPA) Sarah Lo met with Terry Torsu, Youth Counselor, to deliver the finding for the above complaint allegation at Maywright Group Home Short Term Residential Therapeutic Program (STRTP). On 08/29/24, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with three staff (S1, S2, S3), three clients (C2, C3, C4), one past client (PC1) and County Social Worker (CSW). Client #1 (C1) declined to be interviewed. Clients' Needs and Services Plans were reviewed. On August 27, 2024, Community Care Licensing received an allegation that staff do not treat minor (C3) with respect. Specifically, it was reported that a staff called C3 names like "fatty" and "emo boy". (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 12/04/2024

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


raw_content:
Narrative:
Confidential interviews revealed C1 observed S3 drinking alcohol out of a paper cup while S3 was driving but C1 was unable to confirm if it was alcohol that was inside of the paper cup. Additionally, confidential interviews revealed that facility policy does not allow drinking or smoking while they are on the job. Furthermore, confidential interviews revealed that they have not seen or smelled any staff with alcohol while they are on the job. Although the detailed allegation stated that S3 had alcohol in a paper cup during work hours, there were no witnesses to the alleged incident. C1 was not able to be interviewed to confirm or deny the information. Based on confidential interviews, the allegation that S3 was drinking alcohol while caring and supervising C1, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Maywright Group Home Short Term Residential Therapeutic Program (STRTP), Philip Roberts, Administrator.

Investigation Findings:
13On January 02, 2025 at 2: PM, Licensing Program Analyst (LPA) Sarah Lo met with Philip Roberts, Administrator, to deliver the finding for the above complaint allegation at Maywright Group Home Short Term Residential Therapeutic Program (STRTP). On September 04, 2024, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with four staff (S1, S2, S3, S4), three clients (C2, C3, C4), and County Social Worker (CSW). Client #1 (C1) was unable to be interviewed even after several attempts. Clients' Needs and Services Plans were reviewed. On September 03, 2024, Community Care Licensing received an allegation that staff (S3) was drinking alcohol while caring and supervising minors (C1). Specifically, it was reported that S3 had alcohol in a paper cup and was drinking from the cup while supervising C1. (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 01/02/2025

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

met_with: Philip Roberts, Administrator


raw_content:
Narrative:
Interviews further revealed that facility staff were aware that C2 was bullying and intimidating residents and that all clients were afraid of C2. Interviews also revealed that C2 appeared to be under the influence and exhibiting "erratic and dangerous behavior". Additionally, Interviews confirmed that facility did not provide adequate supervision resulting in C1 being injured during the assault. Based on confidential interviews, the preponderance of evidence standard has been met and the allegations that staff did not provide adequate supervision resulting in minors engaging in a physical altercation is substantiated. The facility is being cited for violation of the Interim Licensing Standards Version 5, Article 06, Continuing Requirements regulation 87065.5 (g) Direct Care Staff/Child Ratios. An exit interview was conducted, and a copy of this report along with appeal rights and LIC 811 dated 3/20/25 was provided to Maywright Short Term Residential Therapeutic Program (STRTP), Facility Manager, Philip Roberts.

Investigation Findings:
13On March 20, 2025, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz met with Facility Manager, Philip Roberts, to deliver the finding for the above complaint allegations at Maywright Short Term Residential Therapeutic Program (STRTP). On 09/10/24, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with four Staff (S1-S4), three Clients (C1, C3, C4), Client #2 (C2) was unable to be interviewed. LPA reviewed the following documents in the course of the investigation: Clients' Needs and Services Plans, Staff schedule, Client Roster, C1's medical discharge summary and Special Incident Reports. On September 06, 2024, Community Care Licensing received an allegation stating that staff did not provide adequate supervision resulting in minors engaging in a physical altercation. Specifically, it was reported that C1 was observed with several bruises and a black eye. Confidential interviews revealed that C1 was assaulted in their bedroom by C2 while C3 and C4 held the bedroom door preventing staff from entering. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 03/20/2025

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


raw_content:
Narrative:
Based on confidential interviews, the allegation that due to lack of supervision C1 is using drugs while at the facility, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Maywright Group Home Short Term Residential Therapeutic Program (STRTP), Philip Roberts, Facility Manager.

Investigation Findings:
13On April 03, 2025 at 09:45AM, Licensing Program Analyst (LPA) Sarah Lo met with Philip Roberts, Facility Manager, to deliver the finding for the above complaint allegation at Maywright Group Home Short Term Residential Therapeutic Program (STRTP). On January 21, 2025, Investigation Branch Investigator (INV), Christian Ogata inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation was conducted by INV and included interviews with three staff (S1, S2, S3), STRTP Administrator (AD), and two clients (C1, C2). In addition, Clients' Needs and Services Plans were reviewed. On January 13, 2025, Community Care Licensing received an allegation stating that due to lack of supervision minor (C1) is using drugs while at the facility. Specifically, it was reported that C1 was smoking illicit substance inside of the bedroom. Although the Department received detailed information, the confidential interviews provided inconsistent statements that would validate the allegation and there were no witnesses to the alleged incident. (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/03/2025

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


raw_content:
Narrative:
Although confidential interviews revealed that the clients did smoke and drink in their bedroom, the Department was not able to determine if it was due to a lack of supervision. Confidential interviews entailed that the clients snuck the substances into the facility and waited to consume the alcohol and smoke right after bedroom check. Based on confidential interviews, the allegation that due to lack of supervision (C1, C5) are using drugs and alcohol while at the facility, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Maywright Group Home Short Term Residential Therapeutic Program (STRTP), Phillip Roberts, Facility Manager.

Investigation Findings:
13On September 15, 2025 at 01: PM, Licensing Program Analyst (LPA) Sarah Lo met with Philip Roberts, Facility Manager, to deliver the finding for the above complaint allegation at Maywright Group Home Short Term Residential Therapeutic Program (STRTP). On August 29, 2025, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with one staff (S1), four clients (C1, C2, C3, C4, C6), and County Social Workers (CSW2, CSW3, CSW4, CSW5, CSW6). In addition, the Clients' Needs and Services Plans were reviewed. On August 27, 2025, Community Care Licensing received an allegation stating that due to lack of supervision minors (C1, C5) are using drugs and alcohol while at the facility. Specifically, it was reported that clients were seen smoking and drinking in the bedroom of the group home via a posted video. (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: MAYWRIGHT GROUP HOMEFACILITY NUMBER: VISIT DATE: 09/15/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Veronica Whitaker and Licensing Program Manager, Angela King conducted a case management inspection November 16, 2021, at 10: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 5 of Direct Care Staff and 3 of 3 youth files as identified on the LIC 811 confidential names dated November 16, 2021, were reviewed. 2 of Direct Care Staff and 2 of 3 youth were also interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to Jerome Jordan, Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jerome Jordan


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 7, 2022 at 10: AM, Licensing Program Analysts (LPAs) Karen Beal, Erika Lopez and Licensing Program Manager (LPM) Jennifer Smith arrived at Mayright Group Home Short-Term Residential Therapeutic Program (STRTP). LPAs and LPM were greeted and granted access by Mr. Philip Roberts. The purpose of the visit is to conduct an annual inspection of the facility. There were three staff and three clients present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection. At 11: AM, Mr. Roberts led the physical inspection of the facility. The facility consists of four bedrooms and two bathrooms. The master bedroom is used as the staff office along with the staff restroom. The facility has a dining area within the kitchen area, a living room, a staff office, and a garage. The laundry area is located in the hallway that leads to the garage. There is a large shed in the backyard of the facility that is used as the clinician's office for therapeutic services as well as the case manager's office. There is a window and air conditioning within the building. All bedrooms have individual beds and drawer space for each client. The facility ensures that there is one client per bed and no more than two clients share a bedroom. All client bedrooms have clothing thrown on the floor, dirty dishes and empty food containers. Bedroom #1 has plywood boarding on two of the walls on the left side of the room and a missing window screen. Bedroom #2 has a ceiling fan light bulb that needs to be replaced, the window curtain rod is not secured to the wall and the curtain rod covering the closet is coming away from the wall. Bedroom #3 smells like urine, the wall near the bedroom door is dirty with unknown substance smeared on the wall, the wall has been patched multiple times and needs to painted, the client beds do not have any linens, the curtain for the closet is missing and there is a missing window screen. There was only one set of extra bed linens observed at time of inspection in the hallway cabinet. There was only four client hygiene boxes for six clients at time of visit. LPAs and LPM observed flooring seam cover is broken in the middle in between the laundry room and family room. There is exposed wiring in the hallway where the smoke detector has been removed. There is adequate indoor and outdoor activity space. Books and video games were observed for client's recreation time. The screen for the sliding backyard door is broken and laying against the side of the home. Carbon monoxide detectors are properly working. Fire extinguisher is properly charged and serviced. The facility had a low quantity supply of perishable and non-perishable foods at time of visit. Mr. Roberts stated that their shopping day is tomorrow Saturday October 8, 2022. The facility appears to be following the posted menu. The Visitation Policies, Personal Rights Form, Complaint Procedures and Activities Calendar were not posted at time of inspection. The menu was observed on a bulletin board in the kitchen which Mr. Roberts states it will be hung on the wall. The Foster Care Ombudsman poster was posted in the hallway. Medications are locked and centrally stored in a locked closet in the staff office. Per, Mr. Roberts the facility does not have a locked container for refrigerated medications but there is a refrigerator in the locked garage. Mr. Roberts also states that they do not have individual containers for clients to store contraceptives. LPAs attempted to test the hot water temperature in the client bathroom and the kitchen and the temperature was 81 degrees and did not deliver hot water. Per facility staff, no firearms or weapons are allowed in the facility. Chemicals and/or poisons are locked in a cabinet in the laundry room. Sharp objects are locked and stored in the staff office. First Aid Kits are stored in the staff office and facility vehicle. The first aid kit is missing the first aid manual, scissors and thermometer. The board of director meeting minutes were provided. Facility has obtained National Accreditation through CARF effective through September 28, 2025. The facility licensing fees are current. Copies of the 2022 licensing reports were not available at time of inspection. Based on observation and record review, the licensee is being cited under the following: Title Regulations Physical Plant 80075(g)(1), 80088(b), 80087(a), 80088(e)(1) Interim Licensing Standards(ILS), Short Term Residential Therapeutic Program Articles 1 through 10, Physical Plant 87088(c)(2), 87088(c) and 87088(c)(2)(A). Technical violations are being cited for the following: Title Regulations Physical Plant 80075(j), ILS Physical Plant 87075(b)(1)(A), Operational Requirements 87072.2(a)(3) and Health & Safety Code 1538.5(a)(3). Due to time constraints the annual inspection will be continued on a later date. An exit interview was conducted and a copy of this report and appeal rights were provided to Mr. Roberts.

Deficiencies:
87088(c): Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall provide and make readily available to each child the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2022 at 10: AM, Licensing Program Analysts (LPAs) Karen Beal, Erika Lopez and Licensing Program Manager (LPM) Jennifer Smith arrived at Maywright Group Home Short-Term Residential Therapeutic Program (STRTP). LPAs and LPM were greeted and granted access by Mr. Philip Roberts. The purpose of the visit is to conduct an annual inspection of the facility. There were three staff and three clients present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection. At 11: AM, Mr. Roberts led the physical inspection of the facility. Due to technical difficulties the report and deficiencies will be delivered on a later date. Exit interview and a copy of this report were given and explained on this date.

met_with: Philp Roberts


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 20, 2022 at 9: AM, Licensing Program Analysts (LPAs) Karen Beal, Carmen Escobar and Licensing Program Manager (LPM) Jennifer Smith arrived at Mayright Group Home Short-Term Residential Therapeutic Program (STRTP). LPAs and LPM were greeted and granted access by Mr. Philip Roberts. The purpose of the visit is to conduct a continuation of the annual inspection of the facility that was initiated on October 7, 2022. There was one staff present and six clients present at the time of the inspection. The facility was out of ratio at time of visit. An additional staff (S2) was called to return back to the facility and arrived approximately 10 minutes later. At 10: AM, five of six client files were reviewed during time of inspection. Client files are kept in a locked file cabinet within the staff office, which can also be locked. Client 1 (C1), client 2 (C2), client 3 (C3), client 4 (C4), and client 5's (C5) files were reviewed at time of inspection. C1, C2, and C3's files are missing their signed medical consent forms. C2, C3 and C4 did not have initial medical assessments in their files. All clients, C1-C5, do not have documentation of mental health services received in their files. C3 and C4 did not have proof of TB test results in files. C5 refused to get a TB test. C4 and C5 did not have signatures from their authorized representatives for the complaint, removal/discharge or discipline policies in their files. C1-C5 did not have personal care and grooming needs documented in their needs and service plans. C1, C2, and C5 do not have visitation approval/restrictions documented in their needs and service plans. C1 and C5's needs and service plans are missing signatures by the clients and the client's authorized representatives. C1 does not have a needs and service plan in their file. C2-C5 do not have current needs and service plans in their files. The last needs and service report is dated August 2022. C2 does not have a signed and dated written order from a physician for the non-prescription medication in the file. C1-C5 did not have a bedroom sharing/compatibility review form in their files. During a review of the disaster plan, the location of the utility shut-off valves and instructions were missing. Per Mr. Roberts they do not have it documented in their emergency plan and it is unknown where the valves are located. The facility will be cited under the Interim Licensing Standards (ILS) section Client Records, 87070(b)(11) , 87070(b)(13)(H), 87068.2(b)(6), 87068.2(f), 87068.3(a), 80075(b)(6)(D), Staff & Client Ratios 87065.5(a)(1). Title Regulations Client Records 80069(a), 80069(c)(1), 87087(e), 87070(c)(2), 87068.2(b)(4), 87068.2(f) and Health & Safety Code Disaster Preparedness 1565(a)(6). Due to time constraints the annual will need to be continued on a later date. A copy of this report, advisory notices, and appeal rights, were provided to Acting Facility Manager, Gibron Mall.

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: Philip Roberts, Facility Manager and Gibron Mall, Acting Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 27, 2022 at 9: AM, Licensing Program Analysts (LPA) Jessica Peete and Licensing Program Manager (LPM) Cheraki Davis, conducted an unannounced annual continuation visit at Maywright Short Term Residential Therapeutic Program( STRTP) LPA'S were met at the facility by acting Facility Manager Terry Torsu and Facility Manager Phillip Roberts. The physical plan was inspected on 10/7/2022. At 9:30 am, assisted by the Facility Manager, LPA reviewed five staff files (S1-S5). Regarding staff training the licensee was cited with technical violations in connection with following Interim Licensing Standards (ILS): ILS 87065.1(d)... new direct care staff shall complete a minimum of 24 hours of initial training comprised of the 8 and 16 hour training ILS 87065.1(d)(2) (2) Sixteen hours of training shall be completed by new direct care staff within 90 days of hire. ILS 87065.1(e)(1) Notwithstanding California Code of Regulations, Title 22, Sections 80065(f)(1) through (6), all direct care staff shall complete a minimum of 40 hours of annual training... During the file review LPA observed S1 completed 12 of the required 16 hours of training. Additionally, LPA observed, S2 completed 32 hours, S3 completed 32 hours and, S4 completed 36 hours of the required 40 hours of training. At 10:30 am, LPA observed CPR and first aid certificate for S2 was expired; placing the licensee out of compliance with ILS 87065.1(d)(6)(A) Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association... (Continued on LIC C) At 11:00 am LPA continued with the review of Operational Requirements, Emergency Interventions and Core Therapeutic Services. At the time of inspection the licensee was unable to provide LIC 9165 or LIC 9165A Board of Directors Statement. The licensee was unable to provide documentation of their continuous quality improvement (CQI). The licensee was cited with technical violations in connection with following Interim Licensing Standards (ILS): ILS 87063(c)(4) The licensee shall require that each board of directors or governing body member sign and date the form, LIC 9165A or LIC 9165... ILS 87081(c)(1) A short-term residential therapeutic program's CQI shall: (1) Adopt specific outcomes, indicators, and practice standards, including outcomes associated with trauma informed and culturally relevant services. ILS 87081(c)(2) A short-term residential therapeutic program's CQI shall: (2) Include collecting qualitative and quantitative data and information related to identified outcomes, indicators, and practice standards... ILS 87081(c)(2)(A) A short-term residential therapeutic program's CQI shall: (2) Include collecting qualitative and quantitative data and information related to identified outcomes, indicators, and practice standards. This may include, but is not limited to, the following: (A) Feedback from children, non-minor dependents, families, and staff at all level ILS 87081(c)(2)(C) A short-term residential therapeutic program's CQI shall: (2) Include collecting qualitative and quantitative data and information related to identified outcomes, indicators, and practice standards. This may include, but is not limited to, the following: (C) Peer- review with a short-term residential therapeutic program that serves a similar population or a panel ILS 87081(c)(4) A short-term residential therapeutic program's CQI shall: (4) Utilize data review, analyses, and interpretation to inform and improve policies, practices, and programs. ILS 87081(c)(5) A short-term residential therapeutic program's CQI shall: (5) Include policies and procedures for evaluation of the short-term residential therapeutic program's outcomes and results. LPA conducted two staff interviews ( S1,S2) and two client interviews C4, C7) Based on observations from today's visit, deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights were given to Facility Manager Phillip Roberts.

met_with: Philip Roberts, Facility Manager and Terry Torsu, Acting Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On April 13, 2023 at 1: PM, Licensing Program Analyst (LPA) Lisi Leon arrived unannounced at Maywright Group Home and met with Case Manager, Monika Torres. The purpose of this visit was to conduct a collateral inspection to interview Client #1, C1 (see Confidential Names List Form 811), regarding an open investigation on the client's previous placement. LPA conducted a confidential interview with one client. A copy of this report was given to Case Manager, Monika Torres.

met_with: Case Manager, Monika Torres


summary: Facility Evaluation

raw_content:
Narrative:
On May 19, 2023 at 08: AM, Licensing Program Analyst (LPA), Sarah Lo, arrived at Mayright Group Home Short-Term Residential Therapeutic Program (STRTP). LPA was greeted and granted access by Facility Manager, Philip Roberts. The purpose of the visit is to conduct an annual inspection of the facility. There were three staffs and three clients present at the time of the inspection, however, one of the staff was on the way out to take the three clients to school. Appropriate staff/client ratios were verified during the inspection. At 09: AM, Mr. Roberts led the physical inspection of the facility. The facility consists of four bedrooms and two bathrooms. The master bedroom is used as the staff office along with the staff restroom. The facility has a dining area within the kitchen area, a living room, a staff office, and a garage. The laundry area is located in the hallway that leads to the garage. There is a large shed in the backyard of the facility that is no longer used as the clinician's office for therapeutic services as well as the case manager's office and it is currently used as a storage room. There is a window and air conditioning within the building. All bedrooms have individual beds and drawer space for each client. The facility ensures that there is one client per bed and no more than two clients share a bedroom. LPA began a physical plant inspection at 09: AM and included the following checks: Facility grounds are clean, free of debris and hazards free. There is adequate indoor and outdoor activity space. Computer, books, TV and games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in a locked closet in the living room area. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Chemicals/poisons are locked in a closet next to the laundry room. (continued on LIC-809C) All sharp objects are locked and stored in the locked closet in the living room area. First Aid Kits are stored in the staff office, in the living room and the locked closet where the medication are located. Contraceptives are available in the staff office and is available to be held individually by clients. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Three bedrooms contained two twin beds. The facility has one bathroom for the client to use. The hot water in the client's bathroom was deemed safe and measured between at 107.2 degrees Fahrenheit. Per Facility Manager, no firearms or weapons are allowed in the facility. Administrator, Jerome Jordan is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. The facility employs one facility manager, one assisting facility manager, six direct care staff, one case manager and one therapist. The board of director meeting minutes were provided. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through September 28, 2025. The facility annual licensing fees are paid to current. Licensee has mental health approval and good until June 30, 2023. At 11: AM, five of five client files were reviewed during the time of inspection. Client files were kept in a locked file cabinet within the staff office. At 11: AM, LPA observed C1 was missing the name, address and telephone number of physician/dentist in the medical file. Per CCR 80070(b) Each record must contain information including, but not limited to, the following: (7) Name, address and telephone number of physician and dentist, and other medical and mental health providers, if any. At 11: AM, LPA observed C2 was missing authorization for medical treatment. Per ILS 87070(b) The following information regarding the child shall be obtained and maintained in the child's record: (11) Consent forms, completed by the child's authorized representative(s), to permit the facility to authorize medical care. (continued on LIC 809-c) At 11: AM, LPA observed C2-C5 is missing County Social Worker signature on the Needs and Services Plan. Per ILS 87070(c) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record: (1) A copy of the child's original needs and services plan; verification, signed by the child and their authorized representative(s), that they were offered the opportunity to participate in plan development; and verification that the authorized representative(s) have approved the plan. At 11: AM, LPA observed C3 and C5 was missing signed copies of the facility's policies and procedures regarding the child's removal and/or transfer; discipline; and complaints. Per ILS 87070(c) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record: (2) Signed copies of the facility's policies and procedures regarding the child's removal and/or transfer; discipline; and complaints. At 12: PM, LPA observed C1, C3, C4 and C5 were missing the initial medical examination. Per CCR 80069(a) Except for licensees of ARFs, prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan. At 12: PM, LPA observed C1-C5 were missing tuberculosis (TB) test result. Per CCR 80069(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. LPA was unable to complete the staff/client interviews and staff files due to the staff files are located off-site and Facility Manager is unable to leave the facility to pick up the files. Due to time constraint the annual inspection will be continued on a later date. An exit interview was conducted, a copy of this report and deficiencies, and the appeal rights were given to Facility Manager, Philip Roberts.


summary: Facility Evaluation

raw_content:
Narrative:
On May 30, 2023 at 9: AM, Licensing Program Analyst (LPA) Sarah Lo, conducted an unannounced annual continuation visit at Maywright Short Term Residential Therapeutic Program( STRTP) LPA were met at the facility by Facility Manager Philip Roberts. The physical plan was inspected on May 19, 2023. At 9: AM, LPA conducted two staff interviews and there was two clients at the facility, however, the two clients refused to be interviewed. At 10: AM, LPA reviewed five out of five staff files. No deficiency are being cited. An exit interview was conducted and a copy of this report was given to Facility Manager Phillip Roberts.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived at the facility unannounced to conduct a Case Management - Other investigation. While at the facility LPA obtained the following documents: Medication Administration Record (LIC 622B), Serious Incident Reports, JV223's, and conducted two interviews. LPA informed Facility Manager due to the need to gather additional information this investigation is being extended. The outcome of the investigation will be provided to Facility. An exit interview was conducted, and a copy of this report was provided to Facility Manager, Philip Roberts.


summary: Facility Evaluation

raw_content:
Narrative:
On June 19, 2024 at 09: AM, Licensing Program Analyst (LPA), Rachel Vanegas and Licensing Program Manager (LPM) Jennifer Smith, arrived at Mayright Group Home Short-Term Residential Therapeutic Program (STRTP). LPA was greeted and granted access by Facility Manager, Philip Roberts. The purpose of the visit is to conduct a required annual inspection of the facility. S1, S2, and five clients present at the time of the inspection. However, S2 was on the way out to attend an outside training at 10: AM. The facility was out of staff:client ratio compliance until 02: PM, when S2 returned. At 10: AM, Jerome Jordan - Facility Administrator, led the physical inspection of the facility. S13 arrived during the facility inspection, but does not have the required amount of training hours to count for the staffing ratio. The facility consists of four bedrooms and two bathrooms. The master bedroom is used as the staff office along with the staff restroom. The facility has a dining area within the kitchen space, a living room, a staff office, and an attached garage. The facility sliding door in the kitchen has a screen that was observed to have two small holes. The laundry space is located in the hallway that leads to the garage. There is a large shed in the backyard of the facility that is used as case manager's office and will be used as a temporary storage room. All bedrooms have individual beds and drawer space for each client. The facility ensures that there is one client per bed and no more than two clients share a bedroom. LPA began a physical plant inspection at 10: AM and included the following checks: Facility grounds are clean, free of debris and hazards. There is adequate indoor and outdoor activity space. Computer, books, TV, and games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order and the fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. **Continued on 809-C** Required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, Foster Care Ombudsman poster, and the Emergency Disaster Plan, etc. Medications are locked and centrally stored in a closet in the staff office. Chemicals/poisons are locked in a closet next to the laundry room. All sharp objects are locked and stored in the locked staff office. First Aid Kits are stored in the locked living room closet. Per, administrator and facility manager, individual contraceptive lockboxes are not available for the clients. Bedroom's 2 and 3 were observed to have graffiti on the walls and dressers. C3's bed in bedroom 3 was observed to have a box spring mattress that was not in good repair by having a torn liner, exposing the box spring boards. Three bedrooms contained two twin beds and dressers for each client. Room 1 and Room 2 had exposed closet spaces without a curtain cover(s) or door(s). Bedroom 3 was also observed to have a strong odor of marijuana. The facility has one bathroom for client use. The hot water in the client's restroom was deemed unsafe and measured at 125.4 degrees F. The hot water in the kitchen was also deemed unsafe and measured at 124.7 degrees F. Per Facility Manager, no firearms or weapons are allowed or stored at the facility. Administrator, Jerome Jordan is present at the facility a minimum of 20 hours a week, as verified by staff schedule. The facility employs one administrator, one facility manager, one assistant facility manager, seven youth counselors, one case manager, and two therapists. S3's criminal background clearance has not been associated to the facility. The facility annual licensing fees are paid to current. Licensee has mental health approval and it is valid until June 15, 2025. Due to time constraint, the annual inspection will be continued at a later date to conduct staff and client file reviews. Based on the findings of today's visit, the STRTP will be cited for three Type A and three Type B violations. Two technical violations will be issued as well. **Continued on 809-C** Type A violations are cited under California Code of Regulations (CCR) (Title 22) 80088(e)(1) for hot water temperatures exceeding safe temperatures over 120 degrees F., 80019(e)(3) for S3 not being associated to the facility, and Interim Licensing Standards (ILS) 87065.5(a)(1) due to staff:client ratios between 7am to 10pm not being met. Type B violations are cited under ILS 87088(c)(1) for an individual bed not being maintained in good repair with good springs, CCR 80075(g)(1) for the first aid box not containing adhesive tape, scissors, and bandages, and CCR 80087(a) due to graffiti on the walls and dressers in bedrooms 2 and 3. Two technical violations are issued under CCR 80088(b) due to the sliding screen door not being in good repair and ILS 87075(b)(1)(A) for not providing the children with locked boxes for contraception storage. An immediate civil penalty will be assessed for S3 not being associated to the facility. An exit interview was conducted with Jerome Jordan, Administrator. A copy of this report, 421BG, LIC 811, and the appeal rights were reviewed and provided to Jerome Jordan.

met_with: Jerome Jordan - Administrator Phillip Roberts - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 24, 2024 at 9: AM, Licensing Program Analyst (LPA) Rachel Vanegas and Licensing Program Manager (LPM) Jennifer Smith, conducted an unannounced annual continuation visit at Maywright Short Term Residential Therapeutic Program (STRTP). LPA and LPM were met at the facility by Facility Administrator, Jerome Jordan. The physical plant was inspected on June 19, 2024. LPA and LPM reviewed five staff records and five client records. Five out of six clients in care refused to participate in client interviews. C4 was interviewed. LPA and LPM conducted staff interviews with S1 and S12. Due to technical difficulties, LPA and LPM will return at a later date to provide a detailed report of today's findings. An exit interview was conducted and a copy of this report, LIC Confidential Names List, and Appeal Rights were reviewed and provided to the Facility Administrator, Jerome Jordan.

met_with: Jerome Jordan - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On July 24, 2024, at 01: PM, Licensing Program Analyst (LPA) Rachel Vanegas, arrived unannounced to Maywright Group Home to provide a copy of the completed annual inspection report and findings conducted on 06/24/2024. Due to technical difficulties during the continuation annual inspection on 06/24/2024, LPA was unable to leave the completed report and findings. LPA met with Facility Manager - Philip Roberts. During the visit conducted on 06/24/2024, LPA and Licensing Program Manager (LPM) Jennifer Smith, reviewed five personnel records which contained required and pertinent documents such as duties of the employee, criminal record clearance, health screening clearance, etc. LPA and LPM reviewed five client records which contained required and pertinent documents including: admission agreements, medical consent forms, proper immunization records, etc. Based on the client records review, one technical violations of California Code of Regulations (CCR), Title 22, Section 80075(h)(1) is issued due to children's dental office information not being found in the client records. Based on the client records review, one technical violation of Health and Safety Code, 1565(e)(2) is issued due to the needs and services plans missing for C1, C2, C3, and C4. Based on the client and personnel records review, seven technical violations of Interim Licensing Standards (ILS) are being issued. ILS Section 87065.1(e)(7) for missing training records in personnel files, 87070(b)(12) for client records not having authorized representative signatures on medical consent forms for C2, 87087(e) for three out of three client rooms not having bedroom sharing agreements on file, 87068.2(b)(6) for no mention of family visit frequency and other limitations on the needs and services plans (NSP), 87068.2(f) for the NSP not mentioning the integration of the client family into the treatment process for C6, 87068.2(g) for C1, C2, C3, and C5 not having a NSP on file, and 87070(b)(18)(A) for no documentation on the NSP of the client not being consulted in determining the preferred family members to interact with. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were reviewed and provided to Facility Manager - Philip Roberts.

met_with: Phillip Roberts - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 7/9/25 at 12:00pm based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, 7/9/25). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, and progress notes, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Yem observed training records that show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Jerome Jordan.

met_with: Administrator Jerome Jordan


summary: Facility Evaluation

raw_content:
Narrative:
On June 28, 2021 at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Maywright Residential Therapeutic Program (STRTP). LPA was greeted and granted access by facility manager (FM) Ms. Sheila Evans. The purpose of the visit is to conduct an annual inspection of the facility. There were four staff and five clients present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection. At 10: AM, Ms. Sheila Evans led the physical inspection of the facility with LPA Escobar. The facility consists of four bedrooms and two bathrooms. The master bedroom is used as the staff office along with the staff restroom. The facility has a dining area within the kitchen area, a living room, a staff office, and a garage. The laundry area is located in the hallway that leads to the garage. There is a large shed in the backyard of the facility that is used as the clinician's office for therapeutic services as well as the case manager's office. There is a window and air conditioning within the building. All bedrooms have individual beds and drawer space for each client. Bedroom #3 has large holes in two of the walls and the bedroom door also has a hole in it. The dresser in this room is broken, drawers are broken. There is currently only one client in this room. The facility will be given a technical advisory for these issues as they occurred this morning before LPA's inspection began, during client fight. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair, however, the clients remove the linens to their beds. Facility grounds are clean and free of debris and observable hazards. During the inspection, it was observed that the basketball hoop in the backyard has fallen over and is on the ground, creating a potential hazard. There is adequate indoor and outdoor activity space. Television, computer, board games, video gaming console, and basketball hoop, were observed for client's recreation time. There is no activities calendar posted, however, staff advise due to COVID-19, they are just getting back to scheduling outings and outside activities. LPAs conducted client interviews. Clients indicated that their basic needs are being met at the facility and core services are being provided. LPA Escobar began the review of staff files, however, due to time constraints, was not able to conclude the review. LPA Escobar will return to complete staff file review and interviews at a later date. An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator, Mr. Jerome Jordan. Carbon monoxide detector is in appropriate working order and facility smoke detectors are also in working order. Fire extinguisher is properly charged and serviced. The facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. While the refrigerator in the kitchen had minimal food, both refrigerators in the garage were fully stocked. Per FM, the clients have access to one of the refrigerators for food/snacks. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and stored in a locked box within a locked closet in the staff office. The hot water in the staff and client restrooms was deemed to be at a safe temperature. Per facility staff, there are no firearms or weapons in the facility. Chemicals and/or poisons are locked in a cabinet next to the washer/dryer in the laundry area. Sharp objects/knives are locked and stored in a locked box in the locked closet in the staff office. First Aid Kits are also stored in this locked closet and are complete. A First Aid Manual was also available. It was observed that the licensee has cameras in common areas of the facility as well as the staff office. There is an exception on file for the facility to use the cameras and the facility continues to meet the terms and conditions of the exception, however, the surveillance system is currently not in operating order. Facility will advise when camera system is up and running again. The facility employs one Facility Administrator, six Facility Managers, three direct care youth counselors, one Case Manager, one Head of Service and one Program Director. Facility has not yet obtained Mental Health Certification, however, have submitted the application and are awaiting approval. Facility has obtained National Accreditation through CARF effective through February 28, 2022. Currently, the facility is up to date with Licensing fees for the facility, with a balance of $0. At 10: AM, five of five client files were reviewed during time of inspection. Client files are kept in a locked file cabinet within the staff office. Client 1 (C1), client 2 (C2), client 3 (C3), client 4 (C4), and client 5's (C5) files were reviewed at time of inspection, (See LIC 857) dated June 28, 2021. C3 did not have medical consent form in file. Needs and service plans for C1, C2, and C5 are not current/up to date. The facility will be cited under the Interim Licensing Standards (ILS) section 87068. Modifications to the Needs and Service Plan. C5 did not have proof of current TB test. Technical Assistance Advisory Notes (TA) will be issued for this issue. C3 and C4 are new clients and all missing documents from files will be gathered within 30 days for file completion.

met_with: Administrator-Jerome Jordan and Facility Manager-Sheila Evans


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On June 29, 2021, at 9: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Maywright Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on June 28, 2021. LPA already completed the physical inspection of the facility and reviewed facility client files on the first day of the annual inspection. During this annual inspection continuation, LPA Escobar reviewed ten personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Personnel Files are usually maintained in a locked closet inside the staff office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Eight of the ten files that were reviewed were for employees who converted from group home personnel to STRTP personnel. LPA observed the converted staff members were trained according to the STRTP training requirements for employees. File for staff 1 (S1) did not have current job evaluation. Nine of the ten staff files did not have not have employer verification forms in files. Technical advisories will be issued for the aforementioned staff file issues. Administrator Jerome Jordan states he has been the current administrator since 2018 at the facility, however, no documents or requests for administrator change were made to Community Care Licensing (CCL). Incorrect administrator remains on file. Per interviews conducted, the present administrator is not at the facility as required. Facility will be cited under Interim Licensing Standards section Personnel Requirements. Additionally, eight staff files did not have more than 24 hours of annual training recorded in training file. One staff did not have any annual training hours recorded. Facility will be cited under Interim Licensing Standards section 87065. Training Requirements. Lastly, it could not be determined that staff 10 (S10) meets the direct staff personnel requirements based on personnel record and accompanying employee questionnaire in file. Facility is being cited under Interim Licensing Standards section Personnel Requirements. Administrator Jerome Jordan is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. LPA discussed the following with the Administrator and Facility Manager: incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. On this second day of the continued annual inspection, two youth counselors (direct care staff), one Case Manager, one Facility Manager, and Facility Administrator, were present and were interviewed in regard to their job duties, training, and services provided at the facility. All staff were able to provide sufficient information in relation to the facility's STRTP program. Staff have no issues or concerns regarding the facility. Based upon the inspection of facility records and interviews with staff and clients, the Licensee appears to be meeting CFT and Core Services/Supports requirements. LPA requested the recent board meeting minutes be provided via email by July 6, 2021. LPA also requested an updated LIC500 be sent to LPA as soon as possible. A copy of this report, the advisory notices, and appeal rights, were provided to Facility Administrator, Jerome Jordan.

Deficiencies:
87064(b): (b)  All short-term residential therapeutic programs shall have a qualified and currently certified administrator.
87065: 7.	Relevant life experience in the child welfare, mental health or juvenile justice systems as a consumer, mentor, or caregiver or other relevant experience as determined by the department.

met_with: Facility Administrator-Jerome Jordan

title:
1
2
3
4
5
6
787064 Personnel Requirements

title:
Personnel Requirements
(g) 	 The licensee shall employ the number of direct care staff necessary to comply with the staff to child ratios specified in 87065.5, meet the needs of children as specified in 87065.2, and provide adequate care and supervision to children.
(1) 	Prior to employment, direct care staff shall meet at least one of the 1
2
3
4
5
6
7Review personnell requirements and update S10's file to meet qualifications. Send update to LPA via email.
8
9
10
11
12
13
14qualifications specified in subdivision (A) and have relevant knowledge, skills, and abilities as specified in subdivision (B).
(A)       Direct care staff shall meet one of the following qualifications


summary: Facility Evaluation

raw_content:
Narrative:
*This is an amended report of the original created 01/20/2023* On January 20, 2023, at 3: PM, Licensing Program Analyst (LPA), Carmen Escobar conducted an in-person inspection of Maywright Short Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to interview and obtain statements from clients and staff regarding previous incidents. While LPA conducted a physical inspection of the facility, it was observed that room 1, room 2, and room 3, do not have doors. The doors have been replaced with curtains. By removing all the bedroom doors, the facility is in violation of foster clients' personal rights. The facility is being cited under Interim Licensing Standards (ILS) section 87072, Personal Rights. LPA interviewed parties and a copy of this report, along with appeal rights, was signed by, and provided to Facility Manager, Phillip Roberts, via email due to technical difficulties.

met_with: Youth Counselor-Tanicki Wallace


summary: Facility Evaluation

raw_content:
Narrative:
*This is an amended report of the original dated 02/02/2022* On February 2, 2023, at 2: PM, Licensing Program Analysts (LPAs), Carmen Escobar and Lisi Leon conducted an in-person inspection of Maywright Short Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to conduct a physical inspection of the facility and to verify plan of correction from inspection conducted on 01/20/2023. While LPA conducted a physical inspection of the facility, it was observed that room 1, room 2, and room 3, do not have doors. The doors have been replaced with curtains. By removing all the bedroom doors, the facility is in violation of foster clients' personal rights. The facility is being cited under Interim Licensing Standards (ILS) section 87072, Personal Rights. An exit interview was conducted and a copy of this report, along with appeal rights, was signed by, and provided to Facility Manager, Phillip Roberts, via facility email due to technical difficulties.

met_with: Facility Manager (FM)-Phillip Roberts


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on February 27, 2023 at 9AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Jerome Jordan, Administrator and inspected the facility inside and out. LPA reviewed two of child's records and ## of staff personnel files on site at the facility. LPA reviewed two of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed two of children currently prescribed psychotropic medication. During the inspection the LPA observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Jerome Jordan, Administrator.

met_with: Administrator, Jermone Jordan