summary: Facility Evaluation

raw_content:
Narrative:
On June 1, 2022 at 12: PM, Licensing Program Analyst (LPA) Regina Martin conducted a case management at Bourne Inc. Monterosa for the purpose of assessing an Enhanced Civil Penalty (ECP) as a result of substantiated investigative findings concerning complaint control number 34-CR-20210727144055. LPA met with facility representative named above and discussed the following: On March 22, 2022, LPA Martin conducted a follow-up inspection to deliver a substantiated finding for Neglect/Lack of Care and Supervision. The complaint, which was conducted by CCL Investigations Branch, alleged that the facility failed to properly supervise clients resulting in emergency attention and hospitalization for two clients. The allegation was determined substantiated and the facility was cited for violating California Code of Regulations (CCR) Title 22, 80078(a) Responsibility for Providing Care and Supervision. The Department has concluded an analysis and determined that an Enhanced Civil Penalty is warranted for serious bodily injury. Serious bodily injury is defined in Penal Code section 243 as "a serious impairment of physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of function of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement." Licensee have been found to be liable for the regulator violations. The Department determined issuance of Civil Penalty per Health and Safety Code 1548 (f)(C)(i) For a violation that the department determines constitutes physical abuse, as defined in paragraph (2), or resulted in serious bodily injury, as defined in Section 243 of the Penal Code, to a person receiving care at, but not limited to, short-term residential therapeutic program. The Department will be issuing an immediate Civil Penalty Assessment of $2, 500. A copy of this report, Confidential Names Form, Appeal Rights, and form UC 421-D(CRP) for a Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse were provided to Facility Representative.

met_with: Barbra Waffer, Facility Administrator Martin Gonzalez, Facility Manager


state: CA

facility_name: BOURNE INC. - MONTEROSA

summary: Facility Evaluation

raw_content:
Narrative:
On September 6, 2022 at 9:56am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Monterosa) for the purpose of conducting a Case Management for Special Incident Report #818267 and for a self reported incident for Referral 0000-0988-0921-0025489. LPA met with Martin Gonzalez, Facility Manager and discussed the Special Incident Report and the self reported incident referral which alleges Sexual Abuse, Physical Abuse and General Neglect. During this investigation LPA Edison conducted confidential interviews. Additional confidential interviews will be conducted on a later date. Based on the interviews and information gathered, there was insufficient information to support the allegations occurred. This incident needs further investigation. Based on the observations made during today's visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Martin Gonzalez-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On September 20, 2022 at 10:24am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Monterosa) for a Case Management (Other). The purpose of this visit is the facility is no longer operating per the Board Resolution submitted by Tim Tucker, Executive Director. LPA met with Kashmeir Tucker, Administrator who granted access into facility. The facility is licensed to provide care and supervision for six (6) male children ages 12 -17 years, ambulatory only. The facility is also licensed to provide services to non-minor dependents pursuant to W & I code 16501(C)(1). The census today is zero (0). Upon LPA walkthrough, LPA verified facility is no longer operating. LPA observed no vehicles at the facility. LPA observed that there are no staff at the facility. LPA Edison also confirmed there are no children at this location and that all children have been relocated to another facility. As a result, LPA will process the facility file for closure. Exit Interview was conducted, and a copy of this report will be emailed to the Executive Director and Administrator.

met_with: Kashmeir Tucker-Administrator


facility_name: BOURNE, INC. - THURIN

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On January 6, 2022 at 10:21am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Barbara Waffer, Administrator. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation, a total of three (3) clients and three (3) staff were interviewed. Confidential interviews conducted with Client #1 (C1) confirmed minor AWOL'd from facility. Documentary evidence provided in Special Incident Report (SIR) #786580 confirms that C AWOL'd Confidential interviews also confirm C1's knowledge of the house rules as it relates to the policy on AWOL. LPA obtained signed copies by three (3) clients which include C1 of the policy regarding AWOL. Interviews conducted and review of SIR #786580 produced evidence that confirmed the allegation Minor AWOL'd from facility to be true. C1's admission of AWOLing from the facility support the allegation. LPA Edison was able to determine the above said allegation occurred and that staff at the facility followed all proper policy as it relates to reporting incidents of AWOL of clients in care. Based on the interviews, the information obtained and review of documentation, LPA Edison was able to determine the above said allegations occurred but the facility followed all proper protocols as it relates to the AWOL policy, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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:

report_type: Complaint Investigation

met_with: Barbara Waffer-Administrator

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews also reveal that although COVID positive clients were required to isolate during the required quarantine period, clients refused to comply. Confidential interviews conducted revealed that staff did not make dangerous weapons accessible to minors in care. Based on the interviews conducted, documentary evidence, and the information gathered, the allegations have been determined to be unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that a violation occurred. No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Facility Manager.

Investigation Findings:
13On February 4, 2022 at 1:45pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Vanessa Brissette, Facility Manager. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of four (4) clients and four (4) staff were interviewed. Confidential interviews conducted and documentary evidence for the allegation staff are not implementing proper COVID-19 infection control guidance reveal staff are following proper COVID-19 infection control guidance procedures by ensuring deep cleanings are conducted every two (2) hours. LPA obtained signed copies of the facility's COVID- Cleaning and Disinfection Log for the period of 12/28/2021 through 1/14/2022. Confidential interviews revealed staff required both staff and clients to wear masks at all times and to social distance by maintaining six (6) feet apart. Confidential interviews reveal that clients refuse to comply with this requirement most of the time. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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 El Segundo, CA Facility Name: Bourne, INC. - THURINFACILITY NUMBER: VISIT DATE: 02/04/2022

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

met_with: Vanessa Brissette-Facility Manager


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on the interviews conducted, the preponderance of standard has been met, therefore the above allegations is found to be substantiated. Facility cited on the attached LIC 9099D for violation of California Code of Regulations, Title 22, Division 6, regulation 80072(a)(2) Personal Rights. Facility garage had a mouse and garage smelled of mildew. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

Investigation Findings:
13On April 19, 2022 at 9:51am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Vanessa Brissette, Facility Manager. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of three (3) clients and three (3) staff were interviewed. Confidential interviews revealed there was one (1) mouse in the garage of the facility. Confidential interviews revealed the facility smelled of mildew in the garage due to a water leak in the garage. Continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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 El Segundo, CA Facility Name: Bourne, INC. - THURINFACILITY NUMBER: VISIT DATE: 04/19/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Based on the interviews conducted and documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

Investigation Findings:
13On April 19, 2022 at 11:10am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Vanessa Brissette, Facility Manager. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of three (3) clients and four (4) staff were interviewed. Confidential interviews and documentary evidence of Special Incident Report #793401 did not reveal staff caused injury to a minor while in care, minor is being yelled at while in care, and minor is not afforded privacy while in care. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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 El Segundo, CA Facility Name: Bourne, INC. - THURINFACILITY NUMBER: VISIT DATE: 04/19/2022

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


raw_content:
Narrative:
Based on the interviews conducted, documentary evidence, and LPA observation, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

Investigation Findings:
13On June 21, 2022 at 12:44pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Barbara Waffer, Administrator. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of four (4) staff and two (2) clients were interviewed. Confidential interviews and documentary evidence revealed staff offers nutritious meal options to the clients in care. LPA obtained photocopies of the monthly food menu. Upon LPA observation, food was inspected and observed to be of good quality with current expiration dates. Confidential interviews and documentary evidence also revealed that the facility is sanitary and in good repair and free of foul odors. LPA obtained photocopies of cleaning logs for the facility. Upon LPA observation, the facility is sanitary, free from foul odors and in good repair. Confidential interviews conducted did not reveal that staff did not treat client with respect. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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 El Segundo, CA Facility Name: Bourne, INC. - THURINFACILITY NUMBER: VISIT DATE: 06/21/2022

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


raw_content:
Narrative:
LPA obtained a copy of Special Incident Report (SIR) 797207. LPA attempted to contact Witness #1 (W1) in an effort to locate Client #2 (C2) to conduct an interview for the purpose of discussing the allegations, however, LPA's attempts was unsuccessful in locating and speaking with W1 and C2. Based on the interviews conducted, documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

Investigation Findings:
13On June 21, 2022 at 1:20pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Barbara Waffer, Administrator. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of four (4) staff and three (3) clients were interviewed. Confidential interviews revealed inconsistent statements that staff member handled youth in a rough manner, staff threatened youths, staff members made inappropriate comments to youths, and staff member hit youth. Documentary evidence revealed that Client #2 (C2) threatened Staff #2 (S2) with physical harm. Confidential interviews also revealed that C3 had entered C2's bedroom and refused to return back to their bedroom. Documentary evidence also revealed that inappropriate sexual behavior and inappropriate sexual statements from C2 was the reason staff tried to re-direct C3 back to their own bedroom. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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 El Segundo, CA Facility Name: Bourne, INC. - THURINFACILITY NUMBER: VISIT DATE: 06/21/2022

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


raw_content:
Narrative:
LPA obtained copies of staff ProAct Certifications. Although statements made by C1 revealed that staff slammed C1 against a window, consistent statements revealed staff denied slamming C1 into a window and that C1 hit a living room double-pane window with their elbow and broke the exterior glass. LPA obtained Special Incident Report #840273. Statements by staff and documentary evidence revealed C1 was taken to the hospital, however, confidential interviews revealed doctor's notes stated that there were no bruises, swelling, cuts, or lacerations on C1. Based on the interviews conducted and documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegation. LPA Edison was not able to determine if the above said allegation occurred, therefore the allegation is determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

Investigation Findings:
13On March 28, 2022 at 10:02am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Thurin) and spoke with Barbara Waffer, Administrator. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation LPA Edison interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the allegations. Based on the interviews and statements obtained during the investigation process, the allegation, Staff caused injury to a minor in care, could not be corroborated. Confidential interviews and documentary evidence were reviewed. Confidential statements indicated that Client #1 (C1) was physically aggressive and making homicidal threats toward staff. Staff properly restrained C1 to prevent C1 from physically attacking staff. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison 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 El Segundo, CA Facility Name: Bourne, INC. - THURINFACILITY NUMBER: VISIT DATE: 03/28/2023

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


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The finding is therefore determined Unsubstantiated. A finding that the complaint is unsubstantiated means 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. There were no deficiencies cited per Short-Term Residential Therapeutic Program Interim Licensing Standards or California Code of Regulations, Title 22, at this time. Exit interview completed. A copy of this report was provided to the Facility Representative.

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

met_with: Martin Gonzalez, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On September 3, 2021, at 10:15am Licensing Program Analyst (LPA), Emelyn Sanchez P. arrived at the above facility announced for the purpose of conducting a SB Psychotropic Medication Case Management- Medication Inspection Visit. LPA Sanchez P. met with Vanessa Brisette, Facility Manager. LPA Sanchez P. reviewed four (4) client files and three (3) staff files. LPA Sanchez P. conducted one (1) client interview and three (3) staff interviews. Currently there are six clients residing in the above facility. This is a one story facility located in a residential area and equipped with a kitchen, living room, dinning room, family room/office space, laundry space, three bedrooms and two bathrooms. Attached garage is used for additional storage. Outdoor space is free of obstructions. LPA Sanchez P. observed the facility to be clean, safe, sanitary and in good repair. LPA Sanchez P. observed adequate staffing in the facility to provide care and supervision to children in care. LPA Sanchez P. also observed medication to be centrally stored, double locked and inaccessible to clients and unauthorized staff members. There were no deficiencies cited at this time. Exit interview was conducted, and a copy of this report was left at the facility.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/12/2021 9:30AM Licensing Program Analyst (LPA) Rosslyn Gray and LPA Bernice Karnsrithong made an unannounced to BOURNE, INC. - THURIN for the purpose to conduct the Annual/Required licensing Inspection. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility is licensed to care for 6 clients, female only, ages 12 -17 years, ambulatory only. The facility also provides services to non-minor dependents. The facility acquired The National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF) valid 05/11/2020 through 05/10/2022. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. There are no guns/weapons in the facility. STRTP Overview: This is a one (1) story home three (3) bedroom (STRP) Short Term Residential Therapeutic Program, located in a residential area. There are two (2) bathrooms, living room, dining room, kitchen area. There is a two (2) car garage attached to the main facility. There are two (2) facility vehicles that are parked outside. Temperature and health checks are conducted in the sign-in area. Outdoor Area: The activity space is free of hazard materials and debris. LPAs observed that the perimeter screens of the house were in good condition. LPAs observed the enclosed hot water heater. LPA- Karnsrithong observed a staff displayed the utility shut-off valves. There is shed that is identified as the therapy room. The therapy room has portable air conditioner and art supplies. The therapy is also utilized as a private space to meet with authorized representatives. There is a five feet gated fence that observed to be good condition, it has a swing open entry that leads to the Garden/Orchard area. There are three (3) BBQ pits and a picnic table. The laundry room is equipped with a washer and dryer unit that was observed to be in good condition. The laundry detergent is made inaccessible to the children and is disputed according the load of the laundry. Disinfectants and chemicals are locked in cabinets made inaccessible. Page 1 of Living Room: There is adequate furniture which appears to be in good condition. There is a television and fireplace that is non-operable. Dining Area: One table with six chairs. There is a book shelf that contains books and games for children to use. There is a staff sign-in area next to the dining area. Common Area: There is adequate furniture two (2) sofas, television. There is a sliding glass door. Staff office: Is in the same area common area. It is equipped office furniture (i.e desk, computers, printers. There is vertical window with curtains a sliding glass door that lead to outside area. Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a microwave, refrigerator/freezer and a toaster oven. LPA's observed adequate perishable/nonperishable food supplies. Sharp knives, disinfectants/cleaning solutions made inaccessible to the children. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bedroom # 1: Occupied by one (1) client, the bedroom is equipped two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. There is a ceiling fan. Bedroom # 2: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. There is a ceiling fan. Bedroom # 3: Currently occupied by two (2) but one client is currently hospitalized. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. There is a ceiling fan. Bathrooms: There are two (2)bathrooms. Bathroom #1 is the common bathroom for the clients. It is a full-sized bathroom with a toilet, sink, and tub/showers. Bathroom #2 is located adjacent to the laundry room, this a half bath equipped with toilet, sink and shower that is not being utilized. Both were observed to be clean and operating properly. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Page 2 of The Facility was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Carbon monoxide and smoke detectors are working properly. There are four (4) fire extinguishers and was fully charged. One of the four (4) is located outside in the Shed/Therapy room. Smoke and carbon monoxide detectors were working properly in the facility. LPA observed a First Aid Kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and a 1st Aid Manual. All posting requirements were met. Children will be accorded personal rights. The facility current License, Mental Health Certification; Ombudsperson Grievances and Personal Rights; are posted on the wall. Children are not restricted to make phones calls based on the court and or authorized representative. The therapy room is utilized for clients to make phones calls and the Phone Call Log is kept in the clients file. LPA observed the child's Needs and Services plans kept in the chart; (filed electronic medical records). Children are accompanied to outside extracurricular activities and social events (concerts, NBA, NFL, NHL movies theater, bowling, hiking, swimming etc.) Alternate activities have been implemented. Clients are accompanied park and recreational facilities and amusement parks. Staff Records Review: LPA reviewed five (5) staff records stored in individual personnel file/binders provided by S1. LPA ensured to thoroughly review the records of the primary active staff (i.e The Program Supervisor Administrator, the Facility Manager; and three (3) Direct Care Staff. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the five (5) clients in placement. LPA confirmed that All staff have required criminal record clearance. DOJ, FBI and Child Abuse Response; which meet qualification. Clients Records Review: LPA reviewed five (5) clients records which meet qualification. Staff Interviews: LPA conducted a confidential interview with five (5) on duty staff. Client Interviews: LPA conducted confidential interviews with three (3) of the five (5) clients according to the census as they randomly transitioned from school and were willing to be interviewed. There were no deficiencies cited at this time. LPA's concluded the Annual/Required Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Facility Manager on 10/12/ Page 3 of 3

visit_type: Annual

met_with: FACILITY MANAGER


summary: Facility Evaluation

raw_content:
Narrative:
On February 4, 2022 at 1:35pm, Licensing Program Analyst (LPA), Daphne Edison made an unannounced visit to Bourne Inc. (Thurin) for the purpose of a case managerment visit to address concerns of clients AWOLing and clients smoking marijuana. LPA met with Vanessa Brissette, Facility Manager and discussed the concerns. During this case management, LPA Edison conducted confidential interviews. LPA requested copies of the AWOL procedures and the policy on marijuana use by clients to be emailed to LPA. Based on the interviews, information gathered, there was insufficient information to support the allegations. This case management needs further investigation. No deficiencies were observed or cited at this time. An exit interview was conducted, and a copy of this report will be emailed to the Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios conducted a case management inspection May 12, 2022 at 9:32 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection,9 out of Direct Care Staff and 2 out of 2 youth files were reviewed. 4 out of Direct Care Staff and 2 out of 2 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 12, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Dahl Larios observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Barbara Waffer.

met_with: Administrator Barbara Waffer


summary: Facility Evaluation

raw_content:
Narrative:
On September 6, 2022 at 11:55am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to BOURNE, INC. - THURIN for the purpose of conducting a Case Management Inspection. The clients currently housed at Bourne Inc (Thurin) relocated from Bourne Inc (Monterosa) on August 24, 2022. LPA met with Martin Gonzalez, Facility Manager who granted access into the home and together with LPA, a tour was conducted. The facility is licensed to care for six (6) children, ages 12 -17 years, ambulatory only. The facility also provides services to non-minor dependents pursuant to W & I Code 16501.1(C)(1). There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. The census on the day of this visit is five (5). This is a one (1) story home three (3) bedroom (STRP) Short Term Residential Therapeutic Program, located in a residential area. There is one (1) staff bathroom and one (1) client bathroom, living room, dining room, kitchen area. There is an attached two (2) car garage Temperature and health checks are conducted in the sign-in area. Outdoor Area: The activity space is free of hazard materials and debris. Laundry Room: Equipped with a washer and dryer unit that was observed to be in good condition. Disinfectants and chemicals are locked in cabinets made inaccessible to clients in care. Living Room: Furnished with a sectional sofa, television, screened-in non-operable fireplace, and a table. All furniture is clean and in good repair. Dining Area: Equipped with a table and six (6) chairs. Dining room furniture is in good repair. Continued on LIC 809-C Common Area: Equipped with two (2) sofas and a television. Furniture is clean and in good repair. Staff office: Located in the common area. It is equipped office furniture (i.e desk, computers, printers). Kitchen: There is a gas stove/oven with five (5) burners, all operating. There is a microwave, refrigerator/freezer and a toaster oven. LPA's observed adequate perishable/nonperishable food supplies. Sharp knives, disinfectants/cleaning solutions made inaccessible to the children. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bedroom # 1: Occupied by two (2) clients. The bedroom is equipped two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. There is a ceiling fan. Bedroom # 2: Occupied by one (1) client. The bedroom is equipped with two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. There is a ceiling fan. Bedroom # 3: Occupied by one (1) client. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. There is a ceiling fan. Bathrooms: There are two (2) bathrooms. Bathroom #1 is the common bathroom for the clients. It is a full-sized bathroom with a toilet, sink, and tub/showers. Bathroom #2 is utilized as a staff bathroom and is located adjacent to the laundry room, this a half bath equipped with toilet, sink and shower that is not being utilized. Both were observed to be clean and operating properly. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Continued on LIC 809-C The home is clean, safe, sanitary, and in good repair. Carbon monoxide and smoke detectors tested audible and are working properly. There are four (4) fully charged fire extinguishers located inside of the home. LPA observed a First Aid Kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and a 1st Aid Manual. All posting requirements were met. Children are accorded personal rights. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit Interview conducted, and a copy of this report will be emailed to the Administrator.


facility_name: BOYS REPUBLIC

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Narrative:
Continue from page 1 . . . . The staff denied the allegations and stated that the clients are made to do a self-search when coming back to the facility from their approved community passes by putting their pockets inside out,, shaking their clothing and opening their backups to prevent drugs from coming into the facility. The staff indicated that room searches are done when there is a suspicion of drug possession by a client and that the staff uses a dog to inspect the facility. The staff indicated that clients are provided with support services such as the matrix drug program, individual and family therapy, resident council meetings to discuss concerns in the cottages and CFT's. The confidential interviews indicated that the clients are made to do a self search when they come to the facility, statements were obtained indicating that the clients empty their pockets when coming back from AWOL or the community. The confidential interviews indicated that the clients are unaware of drugs being sold on social media and denied being aware of drug deals being performed as a way of being accepted by other clients in the facility. Interviews also indicated that staff are always monitoring clients for safety and if drugs are found, staff perform the necessary duties to document and report drugs, fights or unauthorized behaviors. The staff and clients indicated that drugs have been an issue on campus and meetings are held to discuss ways to prevent them from coming in. There was no corroborating information obtained through interviews to confirm the allegations. Based on the information obtained through interviews the allegations are found unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the allegations occurred, therefore, the above allegations are Unsubstantiated. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited. An exit interview was conducted, and a signed copy of this report was left with above staff.

Investigation Findings:
13On February 8, 2022, Licensing Program Analyst Claudia Portillo (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegation. LPA Portillo met with the representative above. During the course of the investigation, LPA Portillo conducted phone interviews. LPA interviewed one staff on 01/24/22; two staff on 1/28/22; and two foster children on 2/2/22 (see Confidential Names Form LIC 811 dated February 8, 2022). LPA Portillo attempted to interview client's Probation officer and biological mother but was unsuccessful. LPA Portillo reviewed the facility's incident reports, policy on searches and search warrants, needs and services plan and client's Child and Family Team (CFT) Individualized Care Plan (ICP). It was alleged that Staff do not prevent youth from having access to drugs. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Claudia Portillo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 02/08/2022

met_with: ,Garry Hodge,Treatment Director


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Narrative:
Confidential statements obtained during the investigation were unable to corroborate the allegations as there were no statements obtained to support the allegations. Facility staff denied the allegations of pushed a minor while in care. Facility staff also denied the allegation of hit a minor while in care. Based on the information gathered, the allegations are unsubstantiated as the preponderance of evidence to prove the allegations was not met although the allegations may have happened or is valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On March 9, 2022, Licensing Program Analyst Zeyda Loera (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegation. LPA Loera met with the representative above. During the course of the investigation, LPA Loera conducted interviews. LPA interviewed one staff and foster child on 10/29/21;one staff on 3/2/22 (see Confidential Names Form LIC 811 dated March 9, 2022). LPA Loera reviewed needs and services plan and client's Child and Family Team (CFT) and Individualized Care Plan (ICP) and Staff training record. It was alleged that the Staff pushed a minor while in care, and Staff hit a minor while in care. continuation........................... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Zeyda Loera LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 03/09/2022

met_with: Sterling M.Scott, Associate Director


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Narrative:
Continue from page 1 . . . . The staff denied the allegations and stated that the clients are supervised and the staff indicated that clients are provided with support services if they AWOL. Staff stated the clients have an open campus and could AWOL. They stated there is security and stated measures are taken if they AWOL. Staff stated the client's medication was changed by the facility doctor after careful review. Reporting party was not available to be interviewed. There was no corroborating information obtained through interviews to confirm the allegations. Based on the information obtained through interviews the allegations are found unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the allegations occurred, therefore, the above allegations are Unsubstantiated. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited. An exit interview was conducted, and a signed copy of this report was left with above staff.

Investigation Findings:
13On May 26, 2022 at 8:15AM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up complaint inspection via telephone to Boys Republic and met with staff above. The purpose of the inspection was to deliver findings for the above complaint allegations. During the course of the investigation, LPA Ramos received pertinent documents. Confidential interviews were conducted with client and other relevant parties (see Confidential Names Form dated: 5/26/22). It was alleged staff did not prevent minors from AWOL'ing and staff are mismanaging resident's medication, See LIC 9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 05/26/2022

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

met_with: Jodi Jacobson, HR Director


raw_content:
Narrative:
On August 29, 2022 another notification was made that one (1) child returned to facility and the other two (2) were still outstanding. On September 1, 2022 facility made another notification to all associated parties notifying them of having law enforcement contact regarding one (1) child that was still identified as being a runaway. Interview conducted with witnesses stated that facility did report incidents of children running away from facility and of law enforcement contact. However, interviews conducted with witnesses varied in what details were provided when notifications were made. Additionally, witnesses had similar statements that facility staff contacted them regarding various incidents and interactions involving children. Documents reviewed corroborated with statements made by Director and identified notifications being made to families, law enforcement, probation, and other associated parties. Documents did not identify what was said during notifications but identified who was contacted, their contact information and if additional notifications were made. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On 10/6/ Licensing Program Analyst (LPA) Dawn Mahecha made an unannounced visit to the Boys Republic Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the above identified complaint investigation. LPA met with Administrator and discussed the above complaint findings. Investigation consisted of the following: LPA interviewed (see confidential names dated 9/12/2022). LPA obtained copies of special incident reports (SIRs) from 8/28 to 9/1/22 and contact information to notified agencies. Investigation revealed the following: It was alleged that facility did not notify resident's family of unusual incident. Associate Director denied the allegation. Director stated that family, law enforcement, probation and other associated parties were notified on August 28, 2022 identifying three (3) children running away from facility and that children's beds were closed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 10/06/2022

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

met_with: Gary Hodge, Treatment Director


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Narrative:
Continue from page 1 . . . . Staff#1 denied the allegation and stated that he has never hit any client. Staff stated he did not take any card the client had and confiscated it. Staff supervisor stated staff was good with the clients and stated since he has been working at the group home he has not had any issues with hitting clients and stated he had no concerns. Other clients interviewed did not have any concerns with staff#1. Reporting party was not available to be interviewed. There was no corroborating information obtained through interviews to confirm the allegation. Based on the information obtained through interviews the allegation are found unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the allegation occurred, therefore, the above allegations are Unsubstantiated. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited. An exit interview was conducted, and a signed copy of this report was left with above staff.

Investigation Findings:
13On November 17, 2022 at 8:00AM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up complaint inspection to Boys Republic and met with staff above. The purpose of the inspection was to deliver findings for the above complaint allegation. During the course of the investigation, LPA Ramos received pertinent documents. Confidential interviews were conducted with client and other relevant parties (see Confidential Names Form dated: 11/17/22). It was alleged staff hit a minor while in care. See LIC 9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 11/17/2022

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

met_with: Garry Hodge, Treatment Director


raw_content:
Narrative:
Confidential statements obtained from current and former facility clients facility clients did not provide supporting information to corroborate the allegation. Investigator Hudec was unable to obtain a statement from one of the other facility clients as the child ran away from placement and could not be located. The facility staff also denied the allegation of engaging in any sexual activity with clients at the facility. Based on the information gathered, the allegation is unsubstantiated as the preponderance of evidence to prove the allegation was not met although the allegation may have happened or is valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On December 2, 2022 at 10: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegation above. The complaint was investigated by Community Care Licensing, Investigations Branch, Investigator Brittany Hudec. LPA Rarela discussed the findings with the facility representative named above. During the course of the investigation, Investigator Hudec interviewed the facility director on 9/1/22, facility supervisors on 9/1/22 and 9/20/22, current and former facility clients on 9/1/22, 9/7/22, 9/12/22, 9/20/22, facility clinician on 9/20/22 and facility staff on 9/22/22 (see Confidential Names Form dated December 2, 2022). Investigator Hudec also reviewed documents including placing agency reports and incident reports. It was alleged that facility staff engaged in sexual activity with minors in care. (CONTINUED) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 12/02/2022

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

met_with: Jodi Jacobsen, Human Resources Director


raw_content:
Narrative:
On 10/9/24 the Department received a complaint alleging facility staff provided marijuana to clients in the form of wax pens or puff bars. It was further alleged that clients would pay staff with their allowances for the marijuana. Based on the information gathered during confidential interviews, all relevant parties interviewed denied the allegation. Facility staff denied providing marijuana to the clients in care. Confidential interviews could not corroborate the allegation and clients interviewed denied that staff is providing the clients with marijuana. The other agency's delivered service logs indicated the allegations are historical and the clients mentioned were last placed at the facility in 2022. LPA was unable to interview the clients mentioned due to LPA not being able to locate clients. Clients have been reunified or have aged out of foster care. Based on the interviews and records reviewed the allegation is/are found unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mentioned above. There were no deficiencies cited.

Investigation Findings:
13On January 29, 2025, at 9: AM Licensing Program Analyst Larry Cabral (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegation. LPA Cabral met with the facility associate director Sterling Scott. During the investigation, LPA Cabral interviewed the one facility staff (AD) on 10/17/24. LPA interviewed five facility staff (S2, S3, S4, S5, S6) on 12/12/24. LPA attempted to interview three clients (C1, C2, C3) on 11/7/24. LPA interviewed five clients (C4, C5, C6, C7, C8) on 12/12/24 (see Confidential Names Form LIC 811 dated January 29, 2025). LPA attempted to interview one probation officer (PO) on 10/21/24 and one county social worker on 11/7/24. LPA reviewed the other agency's delivered service logs on 12/14/24. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Larry Cabral LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLICFACILITY NUMBER: VISIT DATE: 01/29/2025

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

met_with: Sterling Scott, Associate Director


summary: Facility Evaluation

raw_content:
Narrative:
On October 13, 2021 at 11:00am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Associate Director, Sterling Scott. The purpose of the case management was to follow up a Special Incident Report (SIR) received by the Department. According to the report, during a weekly house check the staff found three (3) receipts with staff (S1's) name on it inside a pouch on client (C1's) bed. The pouch also contained two (2) letters that suggests a romantic relationship between S1 and C1 but no indication of an intimate relationship. S1 was terminated. At about 11:15am, LPA interviewed Associate Director Scott about the incident. At about 1:30pm, LPA reviewed S1 and C1's records and obtained copies of C1's Needs and Services Plan, Placement Agreement and Discharge Summary, S1's Employment Application, termination letter, the receipts and letters. . Based on the information gathered this incident needs further follow-up at this time. An exit interview was conducted, and a copy of the report was provided to the Associate Director. There were no deficiencies cited at the time of this inspection

met_with: Sterling Scott


summary: Facility Evaluation

raw_content:
Narrative:
On October 13, 2021 at 11:00am, LPA Gilbert Gutierrez made a case management inspection to the facility and met Associate Director Sterling Scott. The purpose of the case management was to follow up on a Special Incident Report (SIR) received by Department According to the report client #1 (C1) masturbated in the presence of client C2 while showering and both clients got into a physical altercation. The date of the incident was unknown. At about 11:50am, LPA conducted interviews regarding the incident. Client C2 stated there was a staff in the hallway when it happened and denied the physical altercation. C2 cannot remember the staff anymore and the date when it happened. C2 stated there are four (4) to five (5) staff in the cottage during daytime and two (2) to three (3) at night supervising the clients all the time. C2 feels safe in the facility. LPA interviewed staff (S1) and S2 regarding the incident. Both confirmed what C2 had stated regarding the number of staff in the cottage during daytime and nighttime. LPA received information that after the incident, only one client is now allowed to take a shower at a time and staff posts just outside the bathroom. LPA finished the interview at about 1:10pm. C1 was already discharged and was not interviewed. Based on the information gathered, the licensee took proper action to address the issue. The incident needs no further follow-up currently. An exit interview was conducted, and a copy of the report was provided to Associate Director Scott. There were no deficiencies cited at the time of this inspection


summary: Facility Evaluation

raw_content:
Narrative:
On October 28 , 2021 at 10:30am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Sterling Scott, Associate Director. The purpose of the case management was to follow up a Special Incident Report (SIR) received by the Department. According to the report, Client (C1) was already 18 years old and living in the Transitional Housing Unit when the staff found three (3) receipts inside a pouch under the name of staff (S1) on C1's bed. The pouch also contained two (2) letters that suggests a romantic relationship between S1 and C1 but no indication of an intimate relationship. S1 was terminated for violation of company rules. On October 14, 2021 at about 11:15am, LPA interviewed Associate Director Scott about the incident. At about 1:30pm, LPA reviewed S1 and C1's records and obtained copies of C1's Needs and Services Plan, Placement Agreement and Discharge Summary, S1's Employment Application, termination letter, the receipts and letters. LPA gathered the information that S1 did not work in the cottages but as a worker at the bakery of the Cafeteria. . On October 18, LPA called both S1 and C1 regarding the incident. Both refused to talk and answer questions regarding their relationship. Based on the foregoing information, no further follow-up will be conducted at this time. However if new information will surface in the future that will shed light to this incident, this will be reopened. An exit interview was conducted, and a copy of the report was provided to the Associate Director Scott. There was no deficiency cited at the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On October 28, 2021 at 10:30am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Sterling Scott, Associate Director. The purpose of the case management was to follow up on a Special Incident Report (SIR) received by the Department. The incident report indicated that an altercation happened between three clients and that client (C1) suffered a small cut on his shoulder caused by a screwdriver that C2 had at the time. A search was conducted and staff located and confiscated the screwdriver. C2 would not state where he obtained the screwdriver. C2 was removed from the facility and his bed was closed. C1 refused to state where he obtained the screwdriver. LPA conducted interviews and interviewed Associate Director Scott at around 11:00am, staff (S1) at around 12:45pm and C3 at around 2:30pm LPA gathered the information that C1 ran away from the facility;and did not come back..C1 denied that C2 had a screwdriver and indicated that C1 only had a scratch and may have come from his nail. After the incident, training sessions were conducted among staff emphasizing the importance of securing all tools or other items that could be used as a weapon and protocols regarding proper response to contraband and weapon possession. . Based on the information, the incident needs further follow-up at this time. An exit interview was conducted and a copy of this report and LIC 811 was provided to Associate Director Scott. There was no deficiency cited at the time of this inspection


summary: Facility Evaluation

raw_content:
Narrative:
On December 2, , 2021 at 9:00am, Licensing Program Analysts (LPAs) Gilbert Gutierrez, Juliet Robles, Karen Suh, and Raymond Wu conducted an annual/required inspection at the Short Term Residential Therapeutic Program (STRTP) and met Sterling Scott, Associate Director. The facility is licensed to serve one hundred twenty (130) males, ages 12-17 and non-minor dependents. There are 49 clients currently placed in the facility. Physical Plant LPAs started the inspection at about 9:30am. Several staff lead the LPAs to inspect the four (4) client cottages,two (2) independent living program homes, cafeteria,, vocational program, and recreation areas, The inspection ended at 11:45am. LPAs observed the following: the posted emergency disaster plan, personnel schedule, clients' personal rights and Foster Care Ombudsman, and grievance procedures. Each bedroom has single beds with clean sheets and linens. There are adequate drawer and closet space for the client's clothing. There are extra linens, adequate towels and hygiene supplies in each facility. Thel window screens are in good repair and free of dirt and other debris. All passageways are unobstructed. The cafeteria/kitchen area was observed to be clean and sanitary. The facility maintains supplies of nonperishable foods for one week and perishable foods for two days. The facility license is posted in the main office building. The cleaning solutions are secured and locked. All medications are centrally stored in the nurse station. No room commonly used for other purposes is being used as a bedroom. LPAs interviewed nine (9) clients and eight (8) staff members at 1:00PM. The interview ended at 2:30pm. At the conclusion of the inspection, LPAs discussed the deficiencies with the associate director. LPAs issued one (1) Type A and one (1) Type B citations. LPAs agreed to work with the facility in clearing the deficiencies. Annual continuation will be continued another day. An exit interview was conducted, and a signed copy of this report, LIC 809, LIC 809Ds and appeal rights were provided to the facility administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 3, , 2021 at 9:00am, Licensing Program Analysts (LPAs) Gilbert Gutierrez, Juliet Robles, Karen Suh, and Raymond Wu conducted an inspection at the Short Term Residential Therapeutic Program (STRTP) and met with Sterling Scott, Associate Director. The purpose of the inspection was to conduct a Case Management Annual Continuation. Staff Records At 9:30am, LPAs reviewed ten (10) staff records and finished at 11:45am. All staff subject to criminal records review have been fingerprinted and cleared. There is documentation of the required education and experience requirements and training in the personnel file. The administrator meets the required qualifications and/or experience. The facility managers meet the requirements. Client Records At around 1:00pm. LPAs reviewed ten (10) client records and finished at 2:30pm. All client records are available to the licensing agency to inspect, audit upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; and medication administration records. LPAs found that Needs and Services Plan (NSP) were signed by authorized representatives. Core/Therapeutic Services The STRTP's primary goal is family reunification. The facility provides mental health services, transition support services; educational and physical, behavioral, and activities to support the children and non-minor dependents to achieve permanency. Disaster Preparedness Plan The facility maintains a current, written disaster plan of action and conducts disaster drill at least quarterly. The drills are documented, and the documentation is maintained in the facility. The facility maintains a register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. No citations issued at this time. An exit interview was conducted, and a signed copy of the LIC 809, LIC 809C,, LIC811s were provided to Human Resources Director Jodi Jacobson.


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2021 at 2:45pm, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Garry Hodge, Treatment Director. The purpose of the case management was to follow-up a report received by the Department on December 6, 2021 that client (C1) is living with his adult girlfriend and to verify that he is no longer a resident of the facility. At around 3:05pm, LPA reviewed C1's records. Based on records review, C1 was placed at the facility on August 31, 2020 and discharged on December 17, 2020. He was re-admitted via the Assessment Center (AC) of Boys Republic on September 21, 2021 while being assessed for a suitable placement. On October 12, 2021, less than 30 days from his admission date, he runaway while attending a court hearing and did not return. Based on the information, this report needs no further follow-up at this time. An exit interview was conducted and a copy of the report was provided to the facility representative.

met_with: Garry Hodge


summary: Facility Evaluation

raw_content:
Narrative:
On August 30, 2022 at 9:15am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Sterling Scott, Associate Director and Garry Hodge, Treatment Director. The purpose of the case management was to follow-up on a Special Incident Report (SIR) received by the Department on 08/22/22 regarding the facility plan to switch to electronic Medication Administration Record (MAR) to reduce clerical errors. Per the SIR, on 08/19/22, the facility Psychiatric Clinic Facilitator (PCF) noticed during review of medication that client (C1) Medication Administration Record (MAR) did not match the prescribed dosage of his medication and it was determined to be a clerical error. The medication is stored in a bubble pack with correct dosage indicating that C1 was administered the correct dosage. A move to electronic MAR is planned. LPA met with Associate Director Scott and discussed the plan to switch to electronic MAR. He stated that they plan to start the electronic MAR in October. The Psychiatrist will input the prescription and dosage in the MAR electronically and nurse will fill out the rest of the information. LPA also met with the facility head nurse. She stated that C1 was always given the correct medication and dosage and not more than or less than what was prescribed. At around 10:30am, LPA reviewed C1's MAR from July 2022. No deficiency citation is issued at the time of the inspection.

met_with: Sterling Scott, Garry Hodge


summary: Facility Evaluation

raw_content:
Narrative:
On October 5, 2022 at 1:00pm, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Robert Cole, Treatment Director. The purpose of the case management was to follow-up on the report the Department received that client #1 was heard (C1) telling his peers about his sexual encounter with a female night staff. On 09/30/22, the Department received a Special Incident Report (SIR). The report indicated that on 09/29/22, a staff overheard C1 during a culinary art class, told his peers that a female overnight staff performed oral sex on him. C1 did not provide any details or identifying information of the staff. LPA conducted interviews at around 1:15pm. LPA met with staff with C1. Staff confirmed that no other details heard regarding the identity of the staff. Treatment Director stated that C1 was not forthcoming about the incident. LPA also learned that there are only 3 female staff working in the cottage where C1 is placed and none of them works overnight. At about 2:00pm, LPA met with C1 and interviewed him about the alleged sexual encounter he had with the female staff. C1 denied saying it or that it happened. LPA reviewed C1's records at around 3:30pm and obtained a copy of the face sheet and Needs and Services Plan. Based on the information gathered. the incident needs no further follow-up currently. An exit interview was conducted and copy of the LIC 809 and LIC 811 was provided to Treatment Director Cole.

met_with: Robert Cole


summary: Facility Evaluation

raw_content:
Narrative:
On February 17, 2022 at 8:45am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Sterling Scott, Associate Director. The purpose of the case management was to follow-up on a Special Incident Report (SIR) received by the Department regarding medication error. Per the SIR, the incident happened during dinner medication distribution at around 6:20pm. Client (C1) denied any pain or discomfort. He was monitored by a staff and did not have any adverse reactions. The nurse supervisor was contacted and was informed of the incident and also the authorized representative of C1. At around 9:05am, LPA met with the nurse supervisor and discussed the incident. She stated that staff (S1) who made the mistake of providing the wrong medication to C1 was provided training on proper medication administration. . At around 9:40am, LPA requested and reviewed S1's records and finished at around 10:00am. Per records review, S1 has the necessary license to administer medication to the clients and received proper training. Section 80075(b)(5)(B) provides that once ordered by the physician the medication is given according to the physician's directions. A deficiency citation is issued to the facility per above section. An exit interview was conducted and a copy of this report, LIC 809D and LIC 811 were provided to Garry Hodge, Treatment Director.

met_with: Sterlng Scott, Garry Hodge


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 9, 2022 at 9:30am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Garry Hodge, Treatment Director. The purpose of the case management was to follow-up on the report the Department received regarding a 17-year-old client who ran away from the facility and later reported deceased. On 08/29/22, the Department received a Special Incident Report (SIR). The report indicated that on 08/28/22,during a routine headcount of clients around 6:00pm, a staff discovered that clients referenced as C1 and C2 ran away after checking their rooms. They did not return and the facility reported the runaway incident to the clients' placing agencies, relatives and to the law enforcement. On 08/31/22, the Department received a report from other sources that C1 was deceased while on runaway status from the facility. On 09/01/22, LPA called the facility regarding the incident and confirmed that they received a call from Los Angeles Police Department (LAPD) informing them about the incident on 09/29/22. The facility reported the law enforcement (LE) contact on 09/1/22 as an addendum to the SIR. Section 80061(b) provides that upon the occurrence, during the operation of the facility, of any of the events specified in (1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours. LPA reviewed C1's records at around 9:45am and obtained a copy of the face sheet, Initial Assessment, Placement Plan, and Needs and Services Plan. LPA conducted interviews of clients at around 10:30am. At around 11:30am, LPA toured the facility. A deficiency citation is issued at the time of the inspection. An exit interview was conducted, and a copy of the LIC 809, LIC 809C, LIC 809D, LIC 811, and Appeal Rights were provided to Garry Hodge, Treatment Director.

Deficiencies:
80061(b): Upon the occurrence, during the operation of the facility, of any of the events specified in (1), a report shall be made to the licensing agency within the agency's next working day during its normal business hour1
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7Licensee will provide training to the staff responsible for reporting incidents regarding Reporting Requirements and will send to the Department the attendance sigh-in sheet either by mail or email on or .
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title:
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7Reporting Requirements


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 6, 2022 at 9:05am, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Sterling Scott, Director. The purpose of the case management was to follow-up on the report the Department received that client C1 was receiving drugs from a staff. On 11/14/22, the Department received a Special Incident Report (SIR) that on 10/26/22, client (C1) reported to the staff that C2 informed him that he is receiving drugs from staff S1 see LIC 811 (Confidential Names List). Both C2 and S1 denied the information. LPA conducted interviews at around 9:30am. LPA met with both clients and interviewed S1 on the phone. Both C2 and S1 denied the allegation. C2 denied making the statement and denied it was true while C1 confirmed the statement. Other information gathered indicated that S1 confiscated contraband from C2 a day prior to the incident. LPA reviewed the client's and staff records at around 11:00am. Based on the information gathered, LPA found the incident needs no further follow-up currently.. see continuation... Also, LPA gathered the information that no report was made by licensee to the Department within the time frame required by the regulation after receiving the information. Section 80061(b) provides that upon the occurrence, during the operation of the facility, of any of the events specified in (1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours Prior to this incident, on 09/09/22, licensee was cited under Section 80061(b for not reporting an incident within the time frame allowed by the regulation A deficiency citation is issued at the time of the inspection. A copy of the LIC 809, LIC 809C, LIC 809D, LIC 421M, LIC 811, Appeal Rights were provided to the facility representative.

Deficiencies:
80061(b): Upon the occurrence, during the operation of the facility, of any of the events specified in (1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours1
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7Licensee states that staff will be trained on reporting requirements and will send the proof of training to the Deaprtement either by mail/email by POC date (12/0922)
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met_with: Lori Kezos, Sterling Scott

title:
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7Reporting Requirements


facility_name: BOYS REPUBLIC - POMONA RESIDENCE

summary: Facility Evaluation

raw_content:
Narrative:
On January 19, 2023 at 9: AM, Licensing Program Analyst (LPA) Gilbert Gutierrez conducted an unannounced annual/required inspection at the Short Term Residential Therapeutic Program (STRTP). At the time of arrival, LPA met Debbie Paker, Assistant Supervisor. Administrator, Chris Colflesh arrived shortly. The facility is a two (2) story home with 4 bedrooms and 6 restrooms. The facility accepts boys ages 13-17 and Non-Minor Dependents (NMD). There are three (3) clients in placement, no NMD. At the time of the inspection, no clients present in the facility. A copy of the Emergency Disaster Plan, Client Roster, and Staff Schedule were provided to LPA. Physical Plant: At about 9: AM, LPA together with Ms. Paker toured the facility. The inspection started on the first floor. The following was observed: the posted facility license, Emergency Disaster Plan, clients' Personal Rights. staff schedule, chores and menu. There were perishable foods in the refrigerator and freezer enough for at least 2 days and non- perishable foods in the pantry enough for a week consumption of the clients. All the confidential files were kept locked inside a cabinet in the staff office. All the sharp knives and sharp utensils were locked inside a cabinet. The first aid kit was complete. There were extra linens, extra towels and hygiene supplies in the facility. All passageways are unobstructed. The video cameras were focused on outside areas of the facility only. All bedrooms are located on the second floor of the home. Each bedroom has two single beds drawers, closet and tables for the clients. Each bedroom has a restroom. The shower room was located outside the bedrooms. The water temperature was tested using a digital thermometer and registered 112 degrees F. The carbon monoxide/smoke alarms were tested and working. Client Records At 10: AM, LPA started reviewing three client records. All client records are available to LPA to review. Client records contain required information including, but not limited to, consent forms, needs and services plan, removal/discipline/complaint procedures, medical assessment, personal property and valuables, education records, personal rights forms and medication administration records. An exit interview was conducted, and a signed copy of LIC 809, LIC 809C, LIC 809D and LIC811s were provided to the facility administrator. A deficiency citation is issued at the time of the inspection.

met_with: Chris Colflesh


summary: Facility Evaluation

raw_content:
Narrative:
On March 9, 2023 at 8: AM, Licensing Program Analyst (LPA) Gilbert Gutierrez arrived at the facility to conduct a continuation of annual/required inspection but no one was at the facility at the time. LPA called the main campus and informed the licensee that LPA was in the facility. At around 10: AM, Assistant Supervisor, Deborah Paker arrived. After a while Treatment Director Rob Cole also arrived. Currently, there are five (5) clients in placement. At the time of the inspection, no clients present in the facility. Staffing: At 10: AM, LPA started to review the staff records. LPA was provided the Personnel Summary Report (LIC 500). LPA reviewed six (6) staff files. All staff files contain the required documentation per Title Regulations. The staff' files contain the Mandated Reporter/acknowledgement form, emergency intervention training and evidence of initial and annual training requirements Facility staff have current CPR/First Aid and at least 40 of annual training. All the staff received criminal record and child abuse index check clearances or exemptions and associated to the facility. At 3: PM LPA started the interview. LPA interviewed two (2) staff and two (20 clients. An exit interview was conducted and a copy of the LIC 809 and LIC 811 (Confidential Names List) were provided to the facility representative. No deficiency citation issued at the time of the inspection.

met_with: Rob Cole, Deborah Paker


summary: Facility Evaluation

raw_content:
Narrative:
On August 30, 2022 at 12:00pm, Licensing Program Analyst (LPA) Gilbert Gutierrez made a case management inspection to the facility and met Tanya Miller Facility Manager/Supervisor. The purpose of the case management was to follow-up on a Special Incident Report (SIR) received by the Department on 08/19/22 regarding medication error. Per the SIR, on 08/18/22, client (C1) was accidentally given the wrong medication by staff (S1), The facility nurse met with C1 on 08/19/22. C1 had no complaints. All staff will be trained on medication administration. At around 12:15pm, LPA reviewed S1's file. Proof of staff training dated 8/23/22 on medication administration was provided to LPA. CCR Section 80075(b)(5)(B) states that once ordered by the physician the medication is given according to the physician's directions. A deficiency citation is issued to the facility per above section. An exit interview was conducted and a copy of LIC 809, LIC 809D, and LIC 811 were provided to the facility representative.

met_with: Tanya Miller


facility_name: BOYS REPUBLIC GRAVES STRTP

raw_content:
Narrative:
page 2... C1, C C3, C4, C8, and C9 (See confidential names list 811) were unable to be interviewed. Interview was conducted with complainant and S1 on September 17, 2024. The investigation revealed the following: It was alleged that Staff did not prevent a minor from being under the influence of a harmful substance, staff did not seek medical attention for a minor, Staff did not notify minor's authorized representatives of incident and staff did not adequately regulate equal phone usage for minors. Review of incident reports submitted on January 2, 2024, January 5, 2024, January 8, 2024 and interview conducted on September 17, 2024 did not prove the allegations. Incident report received January 5, 2024, detailed the medical attention given regarding the January 4, 2024, incident. Incident report received on January 5, 2024, and January 8, 2024, named persons contacted regarding youth involved in the January 4, 2024, incident. The incident report received on January 2, 2024, references the December 31, 2023, phone incident and appears to show staff aware of phone usage. Based on interview conducted, staff was unaware of harmful substances brought into the facilities. Based on the information gathered, although the allegations may have happened or is valid, the preponderance of evidence to prove the allegations was not met, therefore the allegation is unsubstantiated A copy of this report and Appeal Rights were provided to Treatment Director. Exit interview was conducted.

Investigation Findings:
13On September 26, 2024 at 3: P.M. Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced visit to Boys Republic Graves STRTP for the purpose of concluding the above identified complaint investigation. LPA met with Garry Hodge-Treatment Director and discussed complaint findings. The investigation consisted of the following: On January 18, 2024, LPA met with Sterling Scott-Associate Director. LPA requested and reviewed documentation which consisted of LIC 500, current and prior staff roster 12-15-23 to 01-10-24, current and prior client roster 12-15-23 to 01-10-24, notes from 12-15-23 to 01-10-24,proof of on duty staff for those days and incident reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Demetris Teal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLIC GRAVES STRTPFACILITY NUMBER: VISIT DATE: 09/26/2024

met_with: Garry Hodge-Treatment Director


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
page 2....... C1, C C3, C4, C8, and C9 (see confidential names list 811) were unable to be interviewed. Interview was conducted with complainant and S1 on September 17, 2024. The investigation revealed the following: Staff did not prevent minors from engaging in a physical altercation with another minor resulting in injuries Review of incident reports submitted on January 5, 2024, January 8, 2024, interview conducted on September 17, 2024 and emails received on September 17-18, 2024 proved the allegations to be true. Interview conducted with S1 confirmed that on-duty staff were no compliant with Boys Republic Graves STRTP requirements for client supervision. Staff missed social cues and were not actively supervising youth. Incident report received on January 5, 2024 referenced a, "need for proper follow up supervision and protocols to be implemented following the incident by requesting additional supervision...." Emails received show two on-duty staff, written up for "failure to provide appropriate supervision during your shift, which resulted in one student being subjected to three separate incidents of physical assault with three other students over the course of a two hour period. It is a major concern and completely unacceptable that these incidents occurred without your knowledge......" Based on the information gathered, the preponderance of evidence to prove the allegation was met, therefore the allegation is substantiated. Deficiencies were cited during this inspection. See LIC 9099D for deficiencies. . A copy of this report and Appeal Rights were provided to Treatment Director. Exit interview was conducted.

Investigation Findings:
13On September 26, 2024 at 3: P.M. Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced visit to Boys Republic Graves STRTP for the purpose of concluding the above identified complaint investigation. LPA met with Garry Hodge-Treatment Director and discussed complaint findings. The investigation consisted of the following: On January 18, 2024, LPA met with Sterling Scott-Associate Director. LPA requested and reviewed documentation which consisted of LIC 500, current and prior staff roster 12-15-23 to 01-10-24, current and prior client roster 12-15-23 to 01-10-24, notes from 12-15-23 to 01-10-24,proof of on duty staff for those days, incident reports, trainings, suspension and write up reports. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Demetris Teal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BOYS REPUBLIC GRAVES STRTPFACILITY NUMBER: VISIT DATE: 09/26/2024


summary: Facility Evaluation

raw_content:
Narrative:
On 12/13/22 at 9: AM, Licensing Program Manager (LPM) Jean Herring, and Licensing Program Analyst (LPA) Gilbert Gutierrez conducted an announced pre-licensing inspection and Component lll at the above facility address. The purpose of the inspection was to license above facility separate from Boys Republic as the licensed facility, after it was assigned a different address by the City of San Bernardino. LPA met Associate Director, Sterling Scott, Treatment Director, Garry Hodge and Director, Serafin Blau, who gave a tour of the facility. The inspection is considered a relocation. The facility is a one-story home that has 9 bedrooms and 4 bathrooms. There are currently six (6) clients in placement. The following was observed at the time of the inspection. The staff schedule, Emergency Disaster Plan and Foster Youth Rights. Foster Ombudsman phone number and menu. The facility has a staff office, clinician offices, a living room/dayroom equipped with sofas and a TV, a laundry room Seven of the bedrooms have two (2) single beds inside and two bedrooms have one single bed . All the beds have clean mattresses equipped with clean linens and beddings. All the bedrooms have drawers and closet space for the clients' use. The facility has working telephone. There were working smoke/carbon monoxide detectors in the hallways, living room, and in each bedroom. The water temperature in the bathroom sinks was tested (119.3 degrees Fahrenheit) within the temperature allowed by Title Regulations. The centralized heating and air were working. All cleaning solutions were observed locked in cabinets. All medications are centrally stored locked in the Nurse Office located Administration Building. The foods are being prepared in the cafeteria, where the clients and staff eat. There were adequate foods both perishable and non- perishable in the cafeteria. The facility is ready to accept clients after the facility is licensed. The facility provides recreation to the clients where they can lift weights and play pool and table tennis. There is a pool which is also part of their recreation. At around 1: PM, LPM and LPA conducted Component lll with the licensee. The following was discussed: LIC 200: Line 1, The licensee name should be Boys Republic. New LIC 200 with corrections was submitted during the inspection visit. The need for a board resolution designating the administrator. The need for a waiver(s) The licensee will submit the required board resolution by 12/15/22. An exit interview was conducted and copies of the reports were provided to Mr. Hodge.

visit_type: Prelicensing

met_with: Sterling Scott, Garry Hodge, Serafin Blau


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2023 at 9: AM, Licensing Program Analyst (LPA) Gilbert Gutierrez arrived at the facility to conduct a post-licensing inspection. LPA met with Associate Director, Sterling Scott who accompanied this LPA to the site of the facility. Physical Plant The inspection of the facility started at around 10: AM. The facility is a one-story home that has 9 bedrooms and 4 bathrooms. There were three clients placed in this facility. The following was observed at the time of the inspection; posted license, Emergency Disaster Plan and Foster Youth Rights. The facility has a staff office, clinician offices, a living room/dayroom equipped with sofas and a TV, a laundry room. Seven of the bedrooms have two (2) single beds inside and two bedrooms have one single bed. All the beds have clean mattresses equipped with clean linens and beddings. There were drawers and closet space for the clients. There were extra towels, bed linens, and personal hygiene supplies inside the storage room. The smoke/carbon monoxide detectors in the hallways, living room, and inside the bedrooms were working. All cleaning solutions were locked in cabinets. All medications are centrally stored locked in the Nurse Office located in the Administration Building. There were adequate perishable foods for at least 2 days and non-perishable foods for at least 7 days in the cafeteria. The water temperature in the bathroom sink was tested (99.8 degrees Fahrenheit) and found not within the temperature required by Title Regulations. However, licensee was able to bring the temperature up to 117.3, within the required temperature allowed by Regulations before LPA left the facility. All passageways were unobstructed. An exit interview was conducted, and a copy of the report was provided to the facility representative. A deficiency citation was issued at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On April 25, 2023 at 9: AM, Licensing Program Analyst (LPA) Gilbert Gutierrez conducted an inspection at the facility. The inspection was a continuation of the post-licensing inspection.. LPA met with Administrator, Sterling Scott. There were four clients placed in the facility. Licensee provided a copy of the LIC 500, client roster, board minutes meeting, Emergency Disaster Plan, and Activity Report. Client Records All client records reviewed are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms. Staff Records LPA reviewed five personnel records. The personnel records contain required information including, but not limited to, employee's full name, driver's license, date of employment, home address and phone number, documentation of the educational background, training and/or relevant experience, health screening and tuberculosis test documents. Documentation of successful completion of training is maintained in the personnel record for each staff. The administrator has a valid Administrator's certificate. Personnel records are maintained on the licensee, administrator and each employee. All individuals subject to criminal record review have been fingerprinted. Disaster Preparedness Plan Facility maintains a current disaster and mass casualty plan. Facility maintains register of clients, medication records, and contact information for each client's responsible party and physician. The facility conducts emergency drills once a month. · Emergency Intervention Plan The facility has emergency intervention plan. The staff records contain proof of training. An exit interview was conducted and a copy of the LIC 809, LIC 809C, LIC 9102 and LIC 811s were provided to the facility representative. No deficiency citations issued at the time of the inspection.