summary: Facility Evaluation

raw_content:
Narrative:
On March 19, 2026 at approximately 9: AM, Licensing Program Analysts (LPA) Zaria Turner, made an unannounced visit with the purpose of conducting an annual inspection to the above Temporary Shelter Care Facility (TSCF). LPA Turner met with Steven Dogan, Facility Administrator, who granted LPA access to the facility. LPA conducted a walk though of the interior and exterior of the facility. LPA observed the posting of License, Personal Rights, and Emergency Disaster Plan. The facility consists of 3 bedrooms, 2 ½ bathrooms, activity room, kitchen, living room/dining room, storage/pantry room, staff office, intake room, and garage. Each client room is equipped with 2 twin size beds, bedding, 2 bedside tables, and closet space for clothing and personal belongings. The 2 bathrooms at the facility are equipped with working toilets, shower/tub, and running water. The ½ staff bathroom is equipped with a water heater, storage for cleaning supplies, a working toilet, and running water. Upon entry, there is a desk and monitor, a double sided fireplace. The living/dining room is equipped with 2 sofas, 2 side tables, a coffee table, a TV, a TV stand, a rocking chair, and a heavy bag stand. The staff office is equipped with a desk, monitors, a staff and client filing cabinet, and locker. The intake room is equipped with 2 fridges used for medications. lockers, and filing cabinets. The activity room is equipped with a table, 2 sofas, a TV, a TV stand containing board games, and a hammock. The storage/pantry room is equipped with cabinets used to store nonperishable foods, a fridge to store perishable foods, and racks to store extra linens. Continue summary of inspection on 809-C The garage is converted into a storage room equipped with extra toiletries, bedding and linens, cleaning supplies, dining utensils, car seats, and toys/games. There are 4 hall closets. There are 3 hall closets used for extra toiletries, linens, and supplies. There is one hall closet equipped with the HVAC (Heating Ventilation and Air Conditioning Unit). There is a washer and dryer located in the kitchen and cabinets above and below where extra linen, toiletries, and cleaning supplies are kept and locked away. Medication is centrally stored, locked, and inaccessible to clients in care. Disinfectants/cleaning solutions are inaccessible to clients in care and locked, under the kitchen sink, in the ½ staff bathroom, and above the laundry units. The refrigerator temperature is at or below 45 degrees F. There is nonperishable food for one week and fresh perishable food for three days minimum. There are containers to place leftover food. Carbon monoxide and smoke detectors are in working order. Temperature in facility is between 68 degrees F and a maximum of 85 degrees F. Hot Water between 105-120 degrees F. Fire Extinguishers are up to date and in working order. The toilets, bathtubs, and shower fixtures are in good repair. Soap and paper towels are available to clients in care. There is a working telephone accessible to clients. The facility is free of vermin. The backyard contains a concrete area with 2 tables, and 9 chairs. There is a basketball hoop, horizontal bars, and a garden area. There is a detached cottage located in the back of the property. The cottage is equipped with a table, 12 chairs, and a bookshelf. There is a tool shed that is currently not in use. There is no pool on the premises. A total of five staff files and five client files were reviewed. LPA Turner conducted four staff interviews and one client interview. A deficiency and a Technical Violation (TV) was assessed during today's inspection. (See LIC 809-D and LIC TV) An exit interview was conducted with Steven Dogan, Facility Administrator, and a copy of this report was discussed and provided during today's inspection.

met_with: Steven Dogan, Facility Administrator


state: CA

facility_name: FOSTERHOPE SAC. WELCOME HOME

summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
IB Investigator #244 reported that, based on multiple interviews, staff stated they confiscate marijuana and vaping devices from youth but later return them when requested. Staff indicated this practice is part of the facility's Harm Reduction Policy which is against their Program Statement. However, according to statute, smoking is prohibited on facility grounds of a licensed facility. During a walk through of the facility, marijuana remains ("blunts") and vaping devices were seen in plain view in youth bedrooms and common areas. Administration confirmed they were aware of these items. Interviews with both staff and youth also confirmed that minors are allowed to smoke marijuana and nicotine in the backyard. Additionally, a strong smell of marijuana was present throughout the facility, indicating that smoking may also be occurring inside. LPA Turner was notified by staff that a staff member was observed inside the facility actively using a vape device belonging to a youth. Staff described witnessing the individual inhale from the youth's cartridge while on duty and within the facility. Based on LPA Turner and the IB Investigator's observations and interviews which were conducted and records reviewed, there is a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are found to be SUBSTANTIATED. Two Type A Interim Licensing Standards Section 84887(e) Buildings and Grounds and Section 84622(f) Plan of Operation deficiencies are being cited. This document is being amended to include civil penalty assessed. A Failure to Correct / Repeat Violations 421FC hard copy civil penalty is being assessed on 03/24/2026. The updated regulation number issued on 03/19/2026 84887(e) Buildings and Grounds from Interim Licensing Standards for Temporary Shelter Care Facilities Version 2 , effective 01/08/2026 is a repeat violation of California Code of Regulations, Section 84087(c) Buildings and Grounds issued on 11/06/2025 as the language is the same. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On March 19, 2026 approximately 9: AM, Licensing Program Analyst (LPA) Zaria Turner made an unannounced visit to deliver findings to the above facility and met with Facility Administrator, Steven Dogan. Prior to the meeting LPA Turner initiated the complaint investigation on January 27, 2026. No deficiencies were cited during that inspection. LPA Turner requested the following documents: Staff and Client Roster, Staff Schedule, Staff Contact Sheet, Client Face Sheets, Incident Reports for the month of January, and Needs and Services Plans for each client in care. LPA Turner and IB Investigator #244 conducted fifteen interviews between January 27, 2026 and March 12, 2026. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegations and can be substantiated because there were consistent statements throughout the investigation process. Report continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Zaria Turner LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: FOSTERHOPE SAC. WELCOME HOMEFACILITY NUMBER: VISIT DATE: 03/19/2026

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On April 9, 2026 at approximately 11: AM, Licensing Program Analyst (LPA) Zaria Turner, made an unannounced visit to the above Temporary Shelter Care Facility (TSCF) to follow up on an incident report received by the department on February 27, 2026. LPA met with Licensee, Erin Brown. LPA conducted a walk though of the interior and exterior of the facility. LPA Turner conducted one staff interview and one client interview. This case management is closed, no further investigation is needed. An exit interview conducted and a copy of this report was left with Licensee, Erin Brown.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Erin Brown, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2026 at approximately 1: PM, the department conducted an Noncompliance Conference with the above facility for the purposes of initiating a discussion about, deficiencies, current observations, and expectations regarding the facility. Present during the meeting was (LPA) Zaria Turner, Licensing Program Manager (LPM) Connie Goldie, Danielle Walker-Flores, Regional Manager (RM), Margo Castaneda, Assistant Program Administrator (APA), Erin Brown, Licensee, Steven Dogan, Facility Administrator, Alicia Berstein, System of Cares (SOC), Eliana Stein, System of Cares (SOC),Melissa LLoyd, Deputy Director, Felicia Harris, Board Member, Stefanie Vrapi, Board Member. This Noncompliance Conference was called to discuss the following issues or deficiencies: Staff have provided youth with marijuana, vape pens, and cartridges. Staff allow youth residing at the facility to smoke both inside and on facility grounds- repeat deficiency discussed during Informal Meeting on 08/22/2025. Staff have been observed smoking on facility grounds. Additionally, the facility has had three complaints. Nine allegations were substantiated, and four allegations were unsubstantiated. The facility has received two Type A citations including Buildings and Grounds and Plan of Operation and seven Type B citations including Personal Rights, Buildings and Grounds, Plan of Operation, Administrator Qualifications and Duties, Reporting Requirements, Staff/Child Ratios, and Disaster/Mass Casualty Plan. Report continued on LIC 809-C


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. Therefore, the allegation is unsubstantiated. A copy of this report will be emailed to the facility on a later date. There are no deficiencies cited at this time.

Investigation Findings:
13On 11/02/2021 at 8:45am, Licensing Program Analyst (LPA) Bernice Karnsrithong conducted a follow-up complaint inspection and met with Program Manager. The purpose of the inspection was to conduct confidential interviews and deliver findings for the above complaint allegation. During investigation of the allegation minors are smoking marijuana at the facility, LPA conducted confidential interviews and reviewed the Child and Family Team (CFT) Meeting Minutes, Incident Reports, Staff Training Calendar, Emergency Intervention Plan and Emergency Response Services. Confidential interviews and documentary evidence indicated that minors obtain marijuana from the community or while AWOL and return with marijuana substance or under the influence of marijuana. Evidence also indicated that when minors are observed to be under the influence, staff provides crisis communication, redirect minors to surrender the substance, asks to conduct contraband searches and substance use barriers are discussed during CFT meetings. Evidence further indicates staff receives Emergency Intervention trainings as required. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: HATHAWAY SYCAMORES CHILD AND FAMILY SERVICESFACILITY NUMBER: VISIT DATE: 11/02/2021

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

met_with: Program Manager

complaint_status: unsubstantiated


facility_name: MARY GRAHAM CHILDREN'S SHELTER

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Through record review LPA observed and POC for a lack of supervision violation. Staff of the above facility is to check in on children bedrooms every ten minutes. Children were left alone for 15 minutes and staff wasn't aware that client was in another client's room. Client admitted to touching other client inappropriately and admitted to sneaking out of the rooms to be with other clients because facility does not allow clients to be in relationships with other clients in the facility. Based on observation, interviews and record review the preponderance of evidence standard had been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview conducted A copy of this report was left with facility and appeal rights were left with facility as well

Investigation Findings:
13On 8/6/2021) Licensing Program Analyst (LPA) met with Kim Robinson at 12:30pm for the purpose of delivering findings for complaint 23-CR-20210413114947. Prior to meeting LPA Sandles requested and reviewed to have staff schedule and roster for the week of 4/12/2021 and individual service plans for all children in care from 4/12/2021-4/16/2021. LPA opened the 10 day and IB investigator Melissa Burgoon took over the investigation and found that LPA had completed most of the investigation and released the investigation back to LPA Sandles for completion. LPA Sandles reviewed Police report 21-7442 from Stockton police. LPA Sandles also reviewed IB investigator report NA-2321-04083. LPA conducted confidential interviews with three children and one staff. LPA reviewed facility complaint history for past two years and reviewed a plan of correction for a citation that was issued in august of 2020 for lack of supervision. The allegation is that the minor was sexually assaulted by another minor while in care. Interviews from both children in care and staff, along with corroborated statements made in interviews taken by the Stockton Police department and IB investigator Burgoon. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robert Sandles LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/06/2021

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

met_with: Kim Robinson


raw_content:
Narrative:
The investigation included interviews with: Law Enforcement, Mental Health Specialist, Child Protective Services, Social Worker, Facility Staff, client #7, client #8, client #15. Interviews were conducted between 10/6/2021 - 12/16/2021. The investigation included obtaining a Law Enforcement Report. The complaint alleges that client #7 was sexually assaulted by another minor at the facility. Client #7 stated during an interview with the investigator, the incident happened a long time ago. Client #7 already forgot about it. However, did remember that client #8 grabbed his private area. client #8 stated during an interview with the investigator, that client #8 did not touch client #7 in the private area. Facility staff on duty witnessed the incident and stated that client # 8 did not grab client # 7 in the private area. the allegations are determined to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of all reports and appeal rights were provided to the facility via email.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton made an unannounced complaint inspection at the facility on 1/27/2022 at 10:00. LPA Shelton spoke with Stephanie McCoy, Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA Shelton informed Ms. McCoy the case was investigated by the Department's Investigator Sonia Boyal. The investigation included: Initial 10-day complaint inspection on 10/7/2021 which included requesting a Facility Sketch, Staff Phone Lists, Staff Schedule, Children's On-site Report for September-October of 2021, Group Master List for September-October of 2021 and Individual Plan for youths. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 01/27/2022

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

met_with: Stephanie McCoy, Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 03/17/22 at 10:45am to deliver complaint allegation findings. LPA met with Kim Robinson Shelter Supervisor II and discussed the above allegation. LPA Shawndra Miles conducted confidential interviews with one youth and three adults. The interviews were consistent that one youth chose to leave the facility on her own accord. The youth affirms that staff at Mary Graham made every attempt to prevent Y1 from leaving and encouraged Y1 to return to the facility. LPA reviewed the training documentation and affirms the facility had training consistent with regulations. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Kim Robinson Shelter Supervisor II. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Kim Robinson Shelter Supervisor II


raw_content:
Narrative:
Because of the lack of corroboration and limited information, the allegation is determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report and appeals process was provided.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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


raw_content:
Narrative:
Some of the individuals interviewed were present for specific incidents reported in the allegations and some were not but heard about the incident and proceeded to share secondhand information. Additionally, with a few other witnesses to the incidents, there is a refusal to provide information or a lack of remembering what occurred with any detail. Because of the lack of corroboration and/or lack of common recurring themes in the interviews, the allegations are determined to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report and appeals process was provided.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Assistant Director


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

raw_content:
Narrative:
The allegation is whether minor's clothing needs were met while in care or not. A client stated during interview, he did not have enough underwear or pants. Records review of Inventory of clothing at intake, Itemization of resident's personal items and clothing and shopping lists indicates that client arrived with just one set of clothing at intake. Client received 2 pairs of shoes, 3 pairs of socks, 4 pairs of pants, 1 pair of shorts, 8 t-shirts, and 2 sets of pajamas, but, only 2 pairs of underwear. 2 pairs of underwear doesn't meet the standard of appropriate. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division Chapter 5 ) 84072 (6) (A) Personal Rights is being cited on the attached LIC 9099D. Personal Rights deficiency cited and Plan of Correction (POC) was discussed. LPA Goldie conducted exit interview. Facility representative received and understood appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the facility to conduct an unannounced complaint investigation inspection on 08/19/2022 at 2: PM. LPA Goldie spoke with Assistant Director (AD) Kim Robinson to discuss the findings of the complaint investigation and allegations stated above. LPA Goldie informed AD this case was investigated by LPA Goldie after LPA Jessica Caplinger opened complaint. The initial 10-day complaint investigation inspection was conducted at the facility on 06/03/2022 by LPA Caplinger. A walk through of the facility and one interview was conducted with facility staff Kim Robinson Assistant Director. Copies of agency documentation obtained include: Clothing Inventory and Incident Report from one client's file, staff schedules, and current youth roster. Confidential interviews were conducted with 7 agency staff, 9 foster youth, and county social worker from 06/02/2022-08/03/2022. Police report was received and reviewed on 08/15/2022. Continued on LIC C. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/19/2022

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

Deficiencies:
84072: (A) Clothing items, provided the clothes are age-appropriate.

met_with: Assisant Director Kim Robinson

title:
Personal Rights
(6) To be provided with and allowed to possess and use adequate personal items, ..., which includes their own


raw_content:
Narrative:
The allegation is whether or not minor is being provided a safe environment while in care. During confidential interviews, 3 clients out of 9 stated at times, they felt unsafe and that the reason that they felt this way was due to other clients. 2 clients stated that staff allowed kids from other cottages to enter their cottage and that made them feel unsafe but, then stated staff helped them. Inconsistencies exist in these statements and collaboration was not obtained. Staff stated that plans are in place to assist clients who are feeling unsafe. Therefore, it is not possible to determine whether the allegations occurred or not. Based on the investigation, records reviewed and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of all reports and appeal rights were provided to the facility via email with a read receipt.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the facility to conduct an unannounced complaint investigation inspection on 08/19/2022 at 2: PM. LPA Goldie spoke with Assistant Director (AD) Kim Robinson to discuss the findings of the complaint investigation and allegations stated above. LPA Goldie informed AD this case was investigated by LPA Goldie after LPA Jessica Caplinger opened complaint. The initial 10-day complaint investigation inspection was conducted at the facility on 06/03/2022 by LPA Caplinger. A walk through of the facility and one interview was conducted with facility staff Kim Robinson Assistant Director. Copies of agency documentation obtained include: Clothing Inventory and Incident Report from one client's file, staff schedules, and current youth roster. Confidential interviews were conducted with 7 agency staff, 9 foster youth, and county social worker from 06/02/2022-08/03/2022. Police report was received and reviewed on 08/15/2022. Continued on LIC C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/19/2022

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

met_with: Assistant Director Kim Robinson


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The Department has investigated the facility had lack of supervision resulting in inappropriate interactions between clients. C1 stated that C1 was inappropriately touched, and a sexual comment was made by C3. C3 denied inappropriately touching C1 or making a sexual comment. Mary Graham notified the Police regarding the incident and Police interviewed both clients. LPA requested a Police Report and it stated C1 said it occurred and C3 denied it occurred. C2 did not recall and incidents between C1 and C3 occurring. After the incident was reported staff keep C1 and C3 apart. All clients interview stated there was adequate supervision in place and there were at least two staff throughout the day and night. Based on the investigation, records reviewed, and interviews conducted, the complaint findings are UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were given to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 8/24/2022, and LPA spoke with Kim Robinson, Assistant Director to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 5/2/2022. The initial 10-day complaint inspection was conducted by LPAs Jean Stidman and Cecilia Warren, at the agency on 5/2/2022. LPA Shelton interviewed C1, C2, C3, S1 and S2 between 5/2/2022 and 8/18/ UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/24/2022

met_with: Kim Robinson, Assistan Director


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
No title 22 regulations were cited during today's visit. An exit interview was conducted, and a copy of this report, and appeal rights were left with Michelle Deville, SS II, whose signature on this form confirms receipt of these documents.

Investigation Findings:
13Licensing Program Analyst (LPA) Shawndra Miles conducted an unannounced inspection at the agency on 08/29/2022 at 12:50PM to deliver complaint allegation findings. LPA met with Michelle Deville, SS II and discussed the above allegations. LPA conducted confidential interviews with three youths, one adult and reviewed the initial special incident report, dated February 03, 2022. The interviews were consistent the client was touched accidentally while playing with other youth in care. However, the incident was a result of horseplaying. The youth were previously prompted on several occasions to stop but ignored. Based on LPAs observations and interviews which were conducted and record review(s), although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Shawndra Miles LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/29/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 180

met_with: Michelle Deville, SS II


raw_content:
Narrative:
During confidential interviews C1 stated that C1 did not remember being inappropriately touched or hit by another client while at Mary Graham. C2 stated C2 did not hit or touch C1 or witness another client hit or touch C1. C3 did not remember hitting or touching another client inappropriately. Both C1 and C2 stated that there was adequate supervision at Mary Graham. Mary Graham separated C1 and C3 after the incident, filed a SCAR's Report and contacted Law Enforcement. The Police Reported stated that C1 said C3 hit C1 in the noise with a basketball and grabbed his privates. C3 denied the allegations. All clients had already been moved to other placement's when Law Enforcement took the report. Based on the investigation, records reviewed, and interviews conducted, the complaint findings are UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were given to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on August 31, 2022 at 2: PM, and LPA spoke with Stephanie McCoy, Director to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 5/20/2022. The initial 10-day complaint inspection was conducted by LPAs Jean Stidman and Cecilia Warren, at the agency on 5/20/2022 and two staff interviews were conducted. LPA Shelton interviewed the C1, C2 and C3 between 5/20/2022 and 8/26/2022. The Police Report was received on 8/26/2022 and reviewed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/31/2022

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

met_with: Stephanie McCoy, Director


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Narrative:
client in care, there is sufficient evidence to prove an inappropriate sexual comment was made to a client as reported. Staff was unable to adequately redirect the client(s), resulting in a physical altercation between the clients after an additional inappropriate comment was made. Furthermore, confidential interviews show that clients are subjected to repeated threats of violence by other clients. Staff are unable to adequately address or prevent the occurrence of the physical threats in order to safeguard clients in care. As a result of the information obtained, documentation reviewed, confidential interviews conducted with staff and clients, the personal rights allegation that minors are being aggressive to another minor while in care is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. Facility cited for Type A violation of California Code of Regulations, Title Division Six, regulation 84072(d): Personal Rights. The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code section 16001.9, as applicable, including the right to live in a safe, healthy, and comfortable home where they are treated with respect. Investigation shows that children were not provided this right of living in a safe and healthy environment as evidenced by clients making inappropriate sexual comments and threats of harm to other clients which poses an immediate health, safety or personal rights risk to clients in care. Exit interview conducted and documentation provided to Kim Robinson, Assistant Director, including appeal rights. seek medical attention is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and documentation provided to Kim Robinson, Assistant Director.

Investigation Findings:
13Licensing Program Analyst (LPAs) Jean Stidman and Kim Pawlowicz on 12/2/22 at 10:15am and met with Kim Robinson, Assistant Director, to discuss the amended findings of the complaint allegation as stated. LPA Stidman informed Kim Robinson, Assistant Director that the complaint investigation included an initial inspection on 7/21/22 where three clients were interviewed. Interviews were conducted and/or attempted with six staff and one client from 8/1/22 to 8/19/22. Reporting party was interviewed 8/2/22. Records were received from the facility on 9/8/22 and reviewed as part of the complaint investigation. Additional interviews were conducted and/or attempted with 32 previous clients of the facility from 10/14/22 to 10/21/22. Two county social workers were interviewed, and 18 staff were interviewed from 9/22/22 to 10/25/22. Subsequent inspections were made to the facility on 10/19/22, 10/21/22, and 10/25/22 where additional staff and clients were interviewed, and records reviewed while at the facility. Regarding the personal rights allegation that a client made inappropriate comments toward another SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 11/03/2022

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

met_with: Kim Robinson, Assistant Directorr


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Narrative:
there are clients in the care of the shelter that need additional supervision or have behaviors that warrant additional supervision than the other clients and the shelter does not staff to that need. All staff interviewed indicated that C31 (see LIC811 dated 11/3/22) has behaviors that always warrant heightened supervision and possibly one staff assigned to C31, but the facility does not staff to this need. In addition, interviews with staff and clients indicate that staff to client ratios are typically five or six clients to one staff during the day which is out of compliance with the required four clients to one staff. Regarding the allegation that facility staff did not provide supervision to clients involved in the distribution, possession and/or use of marijuana, this allegation is related to the facility not intervening to remove marijuana or other contraband clients are found to be in possession of while at the facility. Ten of twelve clients interviewed confirmed that the staff at the facility would not intervene to stop the clients from smoking marijuana or vapes while in the facility. Clients also stated that staff "don't try" to confiscate drugs or other contraband and that if they are found to be in possession of contraband, the staff write it up, but nothing is done after that. Clients also confirmed that staff in the AFS (Absent from Shelter) cottage, did little to nothing to confiscate contraband or tell clients to not smoke in their rooms in the cottage. One staff interviewed indicated that the clients have a right to smoke, despite being under the legal age limit. Twelve of twelve staff reported that there is very little that they can do to remove contraband because "they have rights" and have been told that they can't touch clients to remove contraband or other unauthorized items. Additionally, the Director reported a lack of drug use training for staff and staff confirmed inadequate training to identify substance use and detection, as addressed in the 9/14/22 complaint findings issued on the same date as the findings for this complaint investigation. Regarding the allegation that facility staff did not provide supervision to clients involved in sexual touching and/or assaulting other clients, this allegation is related to the facility not intervening or being present to stop unwanted or inappropriate touching between clients. Eight of twelve clients interviewed confirmed that they engaged in sexual contact while at the facility and that it was not always consensual. Interviews confirmed that staff either didn't check on them or staff could do little to nothing to stop the interactions. Confidential interviews with clients revealed that staff were either not present or failed to provide adequate care to keep clients safe. One staff interview indicated clients have a right to have sex in the cottage and that staff intervention would only be necessary if a sexual assault were occurring, with the assumption that "the client would ask for help during the assault." One client interviewed stated that they were touched inappropriately by another client at the facility when they were supposed to be in their beds and going to sleep but that staff never came to their room to check on them, thus not preventing the inappropriate touching. Regarding the allegation that facility staff did not provide supervision to clients threatening other clients with violence, this allegation is related to fighting in the cottage, threats of violence from clients to other clients, and clients being physically aggressive towards and hitting clients and staff. Nine of twelve confidential interviews with clients demonstrated that staff did not do what they could to stop fights from turning physical and once they got physical, they did little to stop this too. One client's interview detailed an assault on another client that the client intervened to stop because no staff was present to intervene or prevent the assault. Confidential interviews with clients alerted to staff blaming client(s) by "instigating" incident(s) meaning that a client's behavior leads to or causes assaults. One client reported having to fight three clients with staff present and staff did nothing to intervene. Records reviewed showed that 53 out of 58 staff either did not have MABPro Emergency Intervention training or the certifications were expired. Staff interviewed reported that because the facility does not have enough staff to keep eyes on clients, staff are not appropriately trained in emergency interventions and/or staff are not sufficient in numbers to physically intervene, staff can only verbally redirect clients to comply and hope that clients listen. (The facility not being compliant with this training plan is addressed in the 10/14/22 complaint findings issued on the same date as the findings for this complaint investigation.) As a result of the information obtained, documentation reviewed, confidential interviews conducted with staff and clients, the allegations that the facility maintains an insufficient quantity of staff to meet the needs of the clients in care, facility staff did not provide supervision to clients involved in the distribution, possession and/or use of marijuana, facility staff did not provide supervision to clients involved in sexual touching and/or assaulting other clients, and facility staff did not provide supervision to clients threatening other clients with violence are SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. Facility cited for Type A violation of Transitional Shelter Care Facilities, Interim Licensing Standards, Regulation 84665.5(f): Staff Ratios. Records review, confidential interviews with staff and clients indicate that the facility is not providing the care and supervision needed to keep clients safe, in that the facility is required to evaluate clients and if they require special care and supervision due to age, problem behaviors or other factors, they are to increase the number of on-duty staff. All staff interviewed conformed that the facility is staffed to ratio. The facility is not evaluating the staffing need based on observed unsafe behaviors including but not limited to inappropriate interactions between clients, clients physical and sexually assaulting other clients, clients physically assaulting staff, age of the clients in care, or other observed problem behaviors including possession of drugs, alcohol, and other contraband which poses and immediate risk to the safety of the clients in care. Facility cited for Type A violation of California Code of Regulations, Title Division Six, regulation 80078(a): Responsibility for Providing Care and Supervision. Confidential interviews with staff and clients indicate that the facility is not providing the care and supervision as necessary to meet the clients' needs including having sufficient staff persons on duty to physically intervene in physical altercations or other aggressive behaviors, shadow clients during walkabouts as identified in clients' individualized plans, or when engaging in appropriate or inappropriate activities in the cottages which poses an immediate risk to the clients in the care of the facility. Facility cited for a Type A violation of California Code of Regulations, Title Division Six, regulation 84072(d): Personal Rights. The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code section 16001.9, as applicable, including the right to live in a safe, healthy, and comfortable home where they are treated with respect. Investigation shows that clients were not provided with this right as evidenced by the failure to appropriately staff and provide supervision to prevent or safeguard clients from threats of violence, sexual activity or assaults, and/or the continued possession and use of marijuana in the facility, which poses an immediate health, safety or personal rights risk to the rights of clients to live in a safe and healthy environment as required by this regulation. Exit interview conducted with Ms. McCoy and documents, including appeal rights, were provided via email. "girl...if I wasn't working here I would beat you up" or "[if you mess with my car], I'll lose my job..." where clients perceived an implicit threat of harm. During a client interview, it was reported that staff made a comment that a client may have instigated a fight, insinuating that the client deserved to be attacked by other clients. While these comments were not direct threats, interviews largely supported a lack of trauma-informed care as some staff were reported as being rude and making disparaging remarks to and about clients in care. As a result of interviews conducted with staff and clients the allegation that facility staff threaten and intimidate clients in care is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. McCoy and documentation provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 11/3/22 at 2: PM and met with Stephanie McCoy, Director to discuss the findings of the complaint allegations. LPA Hill informed Ms. McCoy that the complaint investigation included an initial inspection on 9/12/22 where four staff and one client were interviewed. Interviews were conducted and/or attempted with 32 previous clients of the shelter facility from 10/10/22 to 10/21/22. Reporting party was interviewed, two county social workers were interviewed, and 17 staff were interviewed from 10/10/22 to 10/25/22. Subsequent inspections were made to the facility on 10/19/22, 10/20/22, and 10/21/22 where additional staff were interviewed, and records reviewed while at the facility. Regarding the personal rights allegation that the facility maintains an insufficient quantity of staff to meet the needs of the clients in care, this allegation is related to the facility staffing the facility to the ratio of the clients that the shelter has in their care rather than to the need of the clients in the shelter. Investigation shows that SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 11/03/2022

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


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Narrative:
appropriately to stop altercations or other acts of aggression and/or violence. Confidential interviews with staff and clients indicate that the facility does not have sufficiently trained staff to adequately prevent or physically intervene when these physical altercations happen. Evidence showed that of the 58 staff records reviewed, 53 records indicate that staff members are out of compliance, expired or missing, for MABpro (Management of Assaultive Behavior) training. When questioned about emergency intervention training, the Director states that they are in transition to Therapeutic Crisis Intervention (TCI) and is aware that they are currently not in compliance. Nine of twelve confidential interviews with clients demonstrated that staff did not do what they could to stop fights from turning physical or did little to nothing to stop this too. One client's interview detailed an assault on another client that the client intervened to stop because no staff was present to intervene or prevent the assault. Confidential interviews with clients alerted to staff blaming client(s) by "instigating" incident(s) meaning that a client's behavior leads to or causes assaults. One client reported having to fight three clients with staff present and staff did nothing to intervene. (The facility not being compliant with this training plan is addressed in the 10/14/22 complaint findings issued on the same date as the findings for this complaint investigation.) Regarding the allegation that minor's behavior poses a risk to other minors, this allegation is related to the facility not intervening to keep other clients safe when behavioral or aggressive incidents happen at the facility. Investigation shows that there are clients in the care of the shelter that need additional supervision or have behaviors that, when escalated, can pose a danger to other clients in the facility, as shown by the facility's lack of compliance addressed in the 7/18/22 and 9/2/22 complaint findings issued on the same date as the findings for this complaint investigation. All staff interviewed indicated that C31 (see LIC811 dated 11/3/22) has aggressive and violent behaviors that warrant heightened supervision and possibly one staff assigned, but the facility does not staff to this need. Confidential interviews revealed that staff do not physically intervene when altercations happen between clients at the facility due to lack of training. Several client plans revealed the facility failed to identify appropriate intervention plans based on documented child welfare, mental health, and behavioral history of the client to ensure the safety of the subject client and/or other clients in the facility. In regards to placement decisions, staff reported limitations regarding a lack of space or having insufficient information in deciding where to safely place a client at intake. Staff and clients reported placing "behaviorally challenged" clients in a separate cottage (also referred to as the "bad kids cottage" or "AWOL cottage") with no additional staffing or supervision measures despite knowledge of the client(s) history of drug use, physical altercations and prior incidents of running away from the facility. Regarding the allegation that the facility is out ratio, this allegation is related to the facility staffing the facility to the ratio of the clients that the shelter has in their care rather than to the need of the clients in the shelter. Investigation shows staff are frequently out of ratio of four clients to one staff in the cottages and particularly when clients walk out of the cottage, requiring a staff follow. While the regulations allow that additional staff be on call and capable of arriving at the facility (cottage) within 30 minutes, confidential interviews demonstrated that the staff are frequently out of ratio beyond this allowed 30 minutes. Investigation shows that staff to client ratios are typically five or six clients to one staff which is out of compliance with the required four clients to one staff during the day. Multiple confidential client interviews demonstrated that clients in the "bad kid cottage" (also referred to as the "AWOL cottage") were frequently out of ratio as there were frequently more than eight clients but only two staff in the cottage. Regarding the allegation that facility staff are not providing adequate supervision to minors, this allegation is related to the staff not being able to provide the approved interventions for clients in care due to a lack of staffing. Clients identify coping skills in their Individual Plans written and approved by the facility which may include "walkabouts". Interviews demonstrated that this means that when a client gets frustrated or anxious, they can walk about the campus to release feelings of frustration and/or anxiety. However, staff indicate that when a client asks for this, more times than not they have to tell the client to wait for additional staff if additional staff are available to come. In addition, confidential interviews revealed that when staff call for additional staff to perform these functions or to take over for cottage ratio, they are met with staff telling them to "make do." Multiple staff interviews indicate that the facility does not staff to the need of the clients in care rather ratio of the clients in care. Confidential interviews with staff and clients also demonstrated that clients are often caught in explosive or violent incidents at the facility due to not having enough staff to keep clients not involved safe while also intervening to stop behaviors including inappropriate interactions, aggression, and fighting amongst clients. Records reviewed demonstrates that 53 out of 58 staff either did not have MABPro (Management of Assaultive Behavior) training or the certifications were expired. Staff interviewed reported that the facility does not have enough staff to keep eyes on clients, staff are not appropriately trained in emergency interventions and/or staff are not sufficient in numbers to physically intervene and can only verbally redirect clients to comply and hope that they do. Additionally, the Director stated that she does not go out on the floor often to see what is happening. Regarding the allegation that facility staff do not meet the minimum qualifications required, this allegation is related to facility staff not having the appropriate training to meet the needs of clients that are accepted at the facility. All staff interviewed indicated that clients accepted to the facility include developmentally delayed clients, clients with mental health issues, behavioral health issues, violent tendencies, and aggression, to name a few. Several staff reported having inadequate training in order to meet the needs of the clients. One staff indicated the facility does not have adequately trained staff to meet the mental health needs of the clients. Additionally, multiple staff reported not receiving training on trauma-informed care. The Director states that the facility needs training on drug use and dual diagnosed children, and reported Regional Center staff has never come to provide training on dealing with clients with developmental disabilities or autism. Records reviewed indicate that 53 of 58 staff do not have current training in emergency interventions. Confidential interviews also demonstrate that clients are admitted frequently with substance use issues. While staff have received training on Narcan administration for clients, there has been no training provided on substance use and detection. As a result of the information obtained, documentation reviewed, confidential interviews conducted with staff and clients, the allegations that minors are being aggressive to another minor while in care, minor's behavior poses a risk to other minors, facility is out ratio, staff are not providing adequate supervision to minors, and staff do not meet the minimum qualifications required are SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. Facility cited for Type A violation of California Code of Regulations, Title Division Six, regulation 84072(d): Personal Rights. The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code section 16001.9, as applicable, including the right to live in a safe, healthy, and comfortable home where they are treated with respect. Investigation shows that the facility is not staffing the facility to the need of the clients in care to prevent assaults, altercations, or aggression towards other clients or when it is identified that the needs of clients are such that additional staff are warranted which poses an immediate health, safety or personal rights risk to the rights of clients to live in a safe and healthy environment as required by this regulation. Facility cited for Type A violation of Transitional Shelter Care Facilities, Interim Licensing Standards, Regulation 84665.5(b): Staff Ratios. Records review, confidential interviews with staff and clients indicate that the facility is not providing the care and supervision required including meeting the minimum staff ratios of one awake and on duty direct care staff present at the facility for ever four children present at the facility which poses an immediate risk to the safety of the clients in care at the facility. Facility cited for Type A violation of California Code of Regulations, Title Division Six, regulation 80078(a): Responsibility for Providing Care and Supervision. Confidential interviews with staff and clients indicate that the facility is not providing the adequate supervision to clients in care including having sufficient staff persons on duty to provide supervision as needed. Confidential interviews with clients and staff reveal that staff do not have "enough eyes" to maintain supervision, cannot implement clients' coping skills including walkabouts, engage in age and developmentally appropriate activities with the varying ages and developmental needs of the clients in the cottages, or physically intervene in physical or aggressive behaviors, or other behaviors or inappropriate interactions observed due to lack of adequate staffing and staff training which poses an immediate risk to the clients in the care of the facility. Facility cited for Type A violation of Transitional Shelter Care Facilities, Interim Licensing Standards, Regulation 84665.3(b): Additional Staff Training. Records reviewed and interviews conducted indicate that staff have not received specialized training on the specialized needs of children in transition including clients accepted with developmental delays, mental health issues, behavioral health issues, violent tendencies, and aggression or substance use and detection, to name a few. Director states that training is needed in regards to drug use and dual diagnosis clients, and reported nobody from the Regional Center has ever come to provide training on dealing with clients with developmental disabilities or autism, which poses an immediate risk to the safety of the clients in care at the facility. Exit interview was conducted and documents were provided along with appeal rights to Ms. McCoy. staff are notified and told to clean their cottages and additional staff go out to the cottages to ensure that they are meeting ratio. Confidential interviews of staff indicated that certain staff who are "less vocal," tend to be selected to speak with Licensing. During an inspection to the facility on 10/14/22, Licensing received push back from facility supervisors when requesting staff contact information. As a result of confidential interviews conducted with staff and clients, the allegation that staff interfere with licensing inspections is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. McCoy and documentation provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 11/3/22 at 2: PM and met with Stephanie McCoy, Director to discuss the findings of the complaint allegations. LPA Hill informed Ms. McCoy that the complaint investigation included an initial inspection on 9/22/22 where five staff were interviewed. Interviews were conducted and/or attempted with 32 previous clients of the facility from 10/14/22 to 10/21/22. Two county social workers were interviewed, and 18 staff were interviewed from 9/22/22 to 10/25/22. Subsequent inspections were made to the facility on 10/19/22, 10/21/22, and 10/25/22 where additional staff and clients were interviewed, and records reviewed while at the facility. Regarding the personal rights allegation that minors are being aggressive to another minor while in care, this allegation is related to reoccurring fighting or altercations that happen at the facility and staff either not intervening to stop the fights or staff not being sufficient in number to stop the fighting. Licensing obtained videoo evidence depicting physical altercations between clients in the cottages and staff not responding SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 11/03/2022

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


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Narrative:
compliance, expired or missing, for MABpro (Management of Assaultive Behavior) training. When questioned about emergency intervention training, the Director states that they are in transition to Therapeutic Crisis Intervention (TCI) and is aware that they are currently not in compliance and have been out of compliance for some time. As a result of the information obtained, documentation reviewed, confidential interviews conducted with staff and clients, staff are out of compliance with the emergency intervention training plan is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. Facility cited for Type A violation of California Code of Regulations, Title Division Six, regulation 84365.5(b): Staffing Requirements. The facility personnel who will use emergency interventions, must be trained in the appropriate emergency intervention techniques approved to be used by the licensee. Evidence shows that the facility is out of compliance with their emergency intervention training in 53 out of 58 records reviewed on 10/14/22. Staff records showed that the MABpro certificates were either missing or expired. When LPA Hillary Hall contacted the Management of Assaultive Behavior training agency, she was informed that the training was still being conducted in person during the COVID epidemic. In addition, records reviewed that of 39 staff who completed de-escalation training, 38 staff completed the training in December 2018 or January 2019 and one completed the training in December 2020 and seven staff haven't completed the training at all. This poses an immediate health, safety or personal rights risk to clients in care at the facility. Exit interview conducted with Ms. McCoy and documentation provided, including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 11/3/22 at 2: PM and met with Stephanie McCoy, Director to discuss the findings of the complaint allegation. LPA Hill informed Ms. McCoy that the complaint investigation included an initial inspection on 10/14/22 where records were reviewed. Interviews were conducted with staff and clients from 10/14/22 through 10/21/22. Licensing agency also contacted MABpro (Management of Assaultive Behavior) training agency. Regarding the allegation that staff are out of compliance with the Emergency Intervention Training Plan, this allegation is related to staff not having the training necessary to intervene when clients' behaviors are assaultive to other clients in care or staff having the training necessary to physically intervene when clients are exhibiting behaviors that pose an immediate health and safety risk themselves or other clients in care. Evidence showed that of the 58 staff records reviewed, 53 records indicate that staff members are out of SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 11/03/2022

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


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Narrative:
Investigation concluded that C1 did report the incident to a staff at the facility. When interviewed by Investigator Weaver, C1 did remain consistent with their original report to facility staff and with their prior disclosure to LPA Tamara Hill. C2 denied knowing C1 but during an interview, C2 made statements that lead investigator to believe that C2 was not being honest. When facility staff were interviewed, they reported seeing C1 and C2 interacting on the evening of the alleged incident and admitted that it could have been possible for C2 to have entered C1's room undetected due to there not being enough staff to supervise children on the graveyard shift. As a result of the information obtained and interviews conducted the allegation that a lack of care and supervision resulted in an inappropriate interaction between children is SUBSTANTIATED. The facility was cited for Type A violation of Title Division Regulations, Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. The facility did not provide the supervision necessary to prevent an inappropriate interaction between C1 and C2. Exit interview conducted with Ms. McCoy and Ms. Robinson and documents were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection on 1/20/2023 at 11: AM and met with Kim Robinson, Assistant Director and Stephanie McCoy, Director to discuss findings of the allegation as stated. LPA informed Ms. McCoy and Ms. Robinson that the investigation was conducted by Melissa Weaver, Investigator of the Investigations Branch for Community Care Licensing Division. Initial inspection was conducted on 10/13/22 where interviews were conducted, and documents were obtained by the investigator. Investigator also conducted interviews of staff who work at the facility, children in the care of the facility and other parties as part of the investigation from 10/13/2022 through 12/13/2022. Complaint allegation stems from an incident where C2 (see LIC811 dated 1/20/23) entered C1's room and touched C1 inappropriately and no staff were aware or intervened to prevent the inappropriate interaction. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 01/20/2023

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

met_with: Kim Robinson, Assistant Director & Stephanie McCoy, Director


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Narrative:
S1 is seen pushing C1 away from the fight. While it is unclear whether S1 made contact with C1's neck or upper body, S1's contact with C1 was extremely brief and did not depict C1 being choked as described. When interviewed, C1 stated that S1 put their hands on C1's neck, restricting C1's ability to breathe to the point that C1 vomited within minutes of leaving the cottage. Interviews conducted with staff and youth present denied seeing S1 put their hands on C1's neck. Review of the law enforcement report does not show any reports by C1 of S1 putting their hands on C1's neck, causing choking, nor did C1's statements indicate that C1 vomited as a result of such an interaction. While the personal rights violation may have happened however there is not sufficient evidence that it did occur. As a result of the interviews conducted and investigation completed, the allegation that staff inappropriately handled a minor in care is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection on 1/20/23 at 11: AM and met with Kim Robinson, Assistant Director and Stephanie McCoy, Director to discuss findings of the allegation as stated. LPA Hill informed Ms. McCoy and Ms. Robinson that the allegation stems from an incident that took place at the facility on 11/12/21 in which S1 (see LIC811 dated 1/20/23) allegedly conducted an inappropriate restraint on C1. Investigation included an initial inspection conducted on 11/3/22 by LPA Jean Stidman. Subsequent inspections were conducted 12/14/22 and 12/15/22 by LPA Tamara Hill. Video of the alleged incident was provided to Licensing for review. Additional investigation included interviews with three youth and three staff from 11/1/22 to 1/20/23. In addition, LPA Hill obtained a copy of the law enforcement report from the 11/12/21 incident where multiple youth were detained and removed from the facility. The video was reviewed depicting the incident between C1 and S1. The video footage depicts S1 physically intervening between youth fighting in a room. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 01/20/2023

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


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Narrative:
staff. On 1/24/ LPA Stidman interviewed one staff and two clients. On 1/29/ LPA Stidman interviewed four staff. On 1/31/ LPA Tamara Melikian interviewed one client at the Millbrook House, Promesa. Confidential interviews of six staff and three clients as well as records reviewed revealed that multiple staff were present and supervising the clients and could not have prevented a minor from hitting another minor nor prevented the minors from AWOLing. The interviews also revealed that between 3-4 staff were attempting to de-escalate the situations by offering alternative activities or to take a break and to walk away, giving counsel or prompting to the clients and body proxemics to keep residents apart. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Stephanie McCoy Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 2/27/23 at 11:15am to deliver complaint allegation findings. LPA met with Stephanie McCoy Director and discussed the above allegations. During the investigation of staff did not prevent minors from AWOLing and a minor hit another minor, LPAs Jean Stidman and Kim Pawlowicz met with Kim Robinson Assistant Director on 12/29/22, with Stephanie McCoy Director on 1/23/23, with Stephanie McCoy Director and Kim Robinson Assistant Director on 1/24/23 and with Stephanie McCoy Director on 1/27/23. On these inspections, LPA inspected the physical plant inside and out, and observed the facility has four cottages. On 12/29/ LPAs Stidman and Pawlowicz reviewed two client files and obtained the following documents: Admission Report, Behavior & Risk Assessment, Pre-Placement Questionnaire, Individual Plan, Individual Education Plan, and Special Incidents reports. LPAs interviewed one client and one staff. On 1/23/ LPA Stidman reviewed one client file and obtained the following documents: Admission Report, Behavior & Risk Assessment, Pre-Placement Questionnaire, Descriptive Itemization of Resident's Personal Items and Clothing for November 2022 and Individual Plan and interviewed one UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 02/27/2023

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

met_with: Stephanie McCoy Director


raw_content:
Narrative:
LPA interviewed three staff, the reporting party and the county social worker on 4/20/23 and 6/7/23. LPA Stidman and LPA Stephannie Verna attempted to interview one client on 5/24/23, 5/25/23 and 5/31/23. LPA Stidman attempted to interview one staff on 5/16/23, 5/25/23 and 5/31/23. Confidential interviews and records reviewed revealed one staff's conduct and behavior poses a risk to youth in care. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Facility cited for violation of California Code of Regulations, Title 22, Division Six, Chapter 5, Regulation 84072(d)(10) on the attached LIC 9099D. Exit interview conducted and a copy of this report and the appeal rights were left at the facility with Kim Robinson, Assistant Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 6/8/23 at 10:30am to deliver complaint allegation findings. LPA met with Kim Robinson, Assistant Director and discussed the above allegation. During the investigation of Conduct Inimical: Staff conduct, and behavior pose a risk to youth in care, LPA toured the facility with Kim Robinson, Assistant Director on 4/20/23. On this inspection, LPA inspected the physical plant inside and out, reviewed one client and one staff file, and obtained documentation for the complaint investigation from the client file of log of time the client has been on Away From Shelter (AFS) from 3/11/23-4/19/23, Admission Report, Behavior and Risk Assessment, Pre-Placement Questionnaire, Personal Rights, Resident Grievance Procedure, Discharge/Removal Procedure, House Rules, Cell Phone/Electronic Device Policy, Resident Restricted Access, Medical Intake Form, Phone Details, and Informational Plan. LPA obtained copies from the staff file of Personal and Contact Information, Resume, Employment Agreement to Report Child Abuse, Employee Agreement to Report Physical Abuse of Elders and Dependent Adults and a notice of employment status. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 06/08/2023

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: Based on record review and interviews, the licensee did not ensure that client C1 was accorded the personal right to be accorded dignity in his or her personal relationships with staff.
- This poses a potential Health and Safety risk to clients in care. received training on Professional Boundaries and Best Treatment Practices during the trainings on MGCS Basics and Routine Policy and Procedures on 9/9/22.
- The facility will provide documentation of the current staff and clients have received a training on professional boundaries by 7/8/23.

met_with: Kim Robinson, Assistant Director


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Narrative:
Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with LaKeisha Carter, Administrator .

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

met_with: LaKeisha Carter, Administrator


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Narrative:
Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division Six, Regulation 84072(d) Personal Rights, are being cited on the attached LIC 9099D." Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Kim Robinson, Assistant Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 8/1/23 at 1:45pm to deliver complaint allegation findings. LPA met with LaKeisha Carter, Administrator and discussed the above allegations. During the investigation of staff did not seek medical treatment for youth, LPA toured the facility with Kim Robinson Assistant Director on 6/20/23 and 7/12/23. On these inspections, LPA inspected the physical plant inside and out, LPA reviewed two client files and obtained documentation of Admission report, Intake and Behavior & Risk Assessment, Phone Details List, Pre-Placement Questionnaire and individualized Plan for both clients. LPA obtained documentation of MGCS Permanent Release Slip for one client. LPA conducted interviews on 6/14/23, 6/20/23, and 7/12/23 with the reporting party, one staff and one client. Three out of three confidential interviews reported two clients were in a physical altercation which resulted in one client receiving an injury to their head. The injured client requested medical treatment, but the facility failed to obtain medical treatment for the client. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/01/2023

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


raw_content:
Narrative:
recanted. Also, records reviewed revealed staff were actively engaged in de-escalating the clients when the minor was hit. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Kim Robinson, Assistant Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 8/15/23 at 10am to deliver complaint allegation findings. LPA met with Kim Robinson, Assistant Director and discussed the above allegations. During the investigation of staff did not prevent a minor from engaging in inappropriate sexual interactions with another minor while in care and staff did not prevent a minor from hitting another minor while in care, LPA toured the facility with Nancy Stuart Shelter Supervisor II on 5/23/23 and Kim Robinson, Assistant Director on 6/8/23. On these inspections, LPA inspected the physical plant inside and out, reviewed two client files, and obtained documentation of Resident Informational Plan, Resident Hourly Documentation, 10-Minute Bed Checks, medical intake form, Admission report, Intake and Behavior & Risk Assessment, Child and Family Team (CFT) Meeting Referral and CFT Plan, Pre-Placement Questionnaire, Medical Intake form, Special Incident Report and Medical and medication documentation for one client. LPA conducted interviews on 5/23/23, 6/8/23, 8/923 interviewed five staff and two clients. Six out of seven interviews reported there were no inappropriate sexual interactions, and these allegations were UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/15/2023


raw_content:
Narrative:
care. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Kenya Gaston, Shelter Supervisor I.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 8/28/23 at 2:30pm to deliver complaint allegation findings. LPA met with Kenya Gaston, Shelter Supervisor I and discussed the above allegation. During the investigation of staff did not prevent a minor from engaging in inappropriate sexual interactions with another minor while in care, LPA toured the facility with Kim Robinson, Assistant Director on 6/8/23. On this inspection, LPA inspected the physical plant inside and out, obtained a copy of an incident report and reviewed three client files and obtained documentation of Admission report, Intake and Behavior & Risk Assessment, Pre-Placement Questionnaire, CFT and individualized Plan, and interviewed one staff and three clients. LPA interviewed the reporting party on 6/15/23.Three out of five confidential interviews reported the minors did not engage in inappropriate sexual interactions with another minor while in UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/28/2023

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

met_with: Kenya Gaston, Shelter Supervisor I


raw_content:
Narrative:
medical documentation, and individualized Plan for both clients. LPA obtained documentation of MGCS Permanent Release Slip, and My Safety Plan for one client. LPA obtained an LIC Personnel Report dated 7/5/23, Staff Reported Time Summary for 6/21/23, seven staff's documentation of TCI training, and Staff Schedule dated 7/3/23-7/8/23, staff notes of an incident that occurred on 6/21/23 and the facility nurse's notes for one client. LPA conducted interviews with one client and seven staff on 7/5/23, 7/12/23, 7/18/23 and 8/1/23. Seven out of eight interviews reported that staff did not do an inappropriate restraint resulting in an injury to minor in care and one out of eight interviews reported they heard staff make inappropriate comment to minor. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with LaKeisha Carter, Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 8/29/28 at 2:45pm to deliver complaint allegation findings. LPA met withLaKeisha Carter, Director, and discussed the above allegations. During the investigation of staff conducted an inappropriate restraint resulting in an injury to minor in care and staff made inappropriate comment to minor, LPA toured the facility with Kim Robinson, Assistant Director on 7/5/23, 7/12/23 and 7/18/23 and LaKeisha Carter, Director on 8/1/23. On these inspections, LPA inspected the physical plant inside and out, reviewed two client files and obtained documentation of Admission report, Intake and Behavior & Risk Assessment, Phone Details List, Pre-Placement Questionnaire, Cell Phone Electronic Device Agreement, House Rules, UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 08/29/2023

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

met_with: LaKeisha Carter, Director


raw_content:
Narrative:
bank statement which shows a financial transaction from the youth to the staff. Based on LPA's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter Regulation 84072(d)(10) Personal Rights are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Michelle DeVille Shelter Supervisor II.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 11/21/23 at 1:00pm to deliver complaint allegation findings. LPA met with Michelle DeVille Shelter Supervisor II and discussed the above allegation. During the investigation of staff had inappropriate relationship with youth, LPA toured the facility with LaKeisha Carter, Director on 8/29/23 and with Kim Robinson Assistant Director on 9/13/23. On these inspections, LPA inspected the physical plant inside and out and obtained documentation for the complaint investigation of an email and a bank statement. On 9/14/ LPA Stidman obtained documentation for the complaint investigation of one staff's application, contact information and probationary release. LPA's Jean Stidman and Stephannie Verna conducted interviews with the reporting party, two staff, one resource parent and three clients on 8/29/23, 9/13/23, 9/14/23 and 11/9/23.Two out of two youth interviewed reported the staff had an inappropriate relationship with youth. LPA reviewed the SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MARY GRAHAM CHILDREN'S SHELTERFACILITY NUMBER: VISIT DATE: 11/21/2023

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

met_with: Michelle DeVille Shelter Supervisor II