summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post-licensing inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA and Administrator conducted a walk-through of the facility. LPA observed three client bedrooms, one staff office, three full bathrooms, a kitchen, garage, backyard, living room, laundry room, and dining room. LPA observed the facility to be safe, clean, and sanitary. All bedrooms, bathrooms, and kitchen were equipped with all necessary items, which were in good repair. Water temperature in the clients' bathroom measured at 108.8 degrees Fahrenheit, which is within the required range. LPA observed no deficiencies during the walk-through. LPA reviewed the facility's operations. LPA found during the post-licensing inspection at the Licensee's other facility, that the length of time for each hold was not clear in the descriptions as well as there was not a clear licensee post-restraint evaluation. A Technical Violation advisory note was issued for this. LPA completed the Physical Plant, Operations, Core Services and Supports, and Disaster Preparedness domains from the CARE Tool, and no other deficiencies were found. LPA was unable to complete this inspection on this date and will return on another date to do so to complete the staff and client file reviews. An exit interview was conducted with Administrator and a copy of this report will be emailed to him with a read receipt, which will serve as his confirmation for receiving the document.

met_with: Steve Dogan


state: CA

facility_name: MILE HIGH LEGEND HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 8/10/2021, Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post-licensing inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA and Administrator conducted a walk-through of the facility. LPA observed three client bedrooms, one staff office, three full bathrooms, a kitchen, garage, backyard, living room, laundry room, and dining room. LPA observed the facility to be safe, clean, and sanitary. All bedrooms, bathrooms, and kitchen were equipped with all necessary items, which were in good repair. Water temperature in the clients' bathroom measured at 108.8 degrees Fahrenheit, which is within the required range. LPA observed no deficiencies during the walk-through. LPA reviewed the facility's operations. LPA found during the post-licensing inspection at the Licensee's other facility, that the length of time for each hold was not clear in the descriptions as well as there was not a clear licensee post-restraint evaluation. A Technical Violation advisory note was issued for this. LPA completed the Physical Plant, Operations, Core Services and Supports, and Disaster Preparedness domains from the CARE Tool, and no other deficiencies were found. LPA was unable to complete this inspection on this date and returned on 8/11/2021 to complete the staff and client file reviews. On 8/11/2021, LPA completed the remaining domains in the CARE tool: Staffing and Client Records, and reviewed four client files and three staff files. LPA found that all client and staff files were in compliance, except for the following deficiency areas: Technical Violations (No Citation): 1. S1's Health Screening was not filled out by the physician. 2. C1 has not had a TB test in the five months that C1 has been placed, however, an appointment to do so is already scheduled. 3. C2 and C3 had no mention of money-handling capability in their Needs and Services Plans. 4. Client room sharing compatibility assessments were not completed. 5. C1's visitation information has not been completed. 6. There is no expiration date for medication on the Medication Administration Records, however, it is on the actual medication bottles. Citation - Type B: 1. S2 had 25 hours of verifiable annual training, which is under the required amount of 40 hours annually. Note: these Technical Violation Advisory Notes and B Citation were already issued during the post-licensing inspection. An exit interview was conducted with Administrator and a copy of this report will be emailed to him with a read receipt which will serve as the record of receipt for the documents.

report_type: Facility Evaluation


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post-licensing inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA completed the remaining domains in the CARE tool: Staffing and Client Records, and reviewed four client files and three staff files. LPA found that all client and staff files were in compliance, except for the following deficiency areas: Technical Violations (No Citation): 1. S1's Health Screening was not filled out by the physician. 2. C1 has not had a TB test in the five months that C1 has been placed, however, an appointment to do so is already scheduled. 3. C2 and C3 had no mention of money-handling capability in their Needs and Services Plans. 4. Client room sharing compatibility assessments were not completed. 5. C1's visitation information has not been completed. 6. There is no expiration date for medication on the Medication Administration Records, however, it is on the actual medication bottles. Citation - Type B: 1. S2 had 25 hours of verifiable annual training, which is under the required amount of 40 hours annually. An exit interview was conducted with Administrator and a copy of this report will be emailed to him with a read receipt which will serve as the record of receipt for the documents.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual inspection at the facility and met with staff Candace Hill who assisted with the inspection. Later, LPA also met with Administrator Steve Dogan. LPA and Staff conducted a walk-through of the home and LPA observed three client bedrooms, two pantries, one hall closet, one kitchen, two living rooms, a staff office/therapy office space, the backyard, a laundry room, and the garage. LPA observed no deficiencies. LPA observed there were no more towels in the clients' bathroom, however there were more in the house, and they were placed in the bathroom. LPA observed an adequate amount of food and supplies for the clients. There were two clients present at the time, home for Spring Break, and one staff present. LPA interviewed two clients and one staff. LPA observed some Department reports from 2016 to 2020, however newer reports were not maintained at the facility. LPA also observed the register of clients, a required. LPA moved to the Administrative Office located at Georgia St., Vallejo, CA 94590 to conduct the file reviews. LPA reviewed the facility's emergency drill records and found that they have conducted the required emergency drills. The facility is up-to-date on their Licensing bills/fees. LPA reviewed the Board of Director's meeting minutes for the past year and found them to have met as required for December 2022 (Q4). Administrator attempted to get the records for 2022Q2, 2022Q3, and 2023Q1, however, was not able to on this date. LPA reviewed the ProACT trainer certification, training materials, and training records for staff and found it to meet the requirements, however, no competency tests are being conducted. Additionally, no staff are being trained annually on the Emergency Disaster Plan as required. LPA reviewed fingerprint clearances for the staff at the facility and found: All staff are associated as required, however one staff (S1) had errors in their name and date of birth, which will need to be corrected. LPA is unable to complete this inspection on this date. LPA will return at a later date to complete the file reviews. On this date, the facility is being cited for violations of the Health and Safety Code Section 1565(b), and Short Term Residential Therapeutic Program Interim Licensing Standards Section 87095.65(b)(6). Five advisory notes, which are not citations, are being issued as well. An exit interview was conducted with Administrator and a copy of this report, confidential names list, and appeal rights were left with him.

visit_type: Annual

met_with: Candace Hill, Steve Dogan


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual continuation inspection at the Administrative Office located at Georgia St., Vallejo, CA 94590 and met with Administrator Steve Dogan, who assisted with the inspection. LPA received 2022Q2 and 2022Q Board Meeting Minutes. In the meeting minutes for both meetings, discussed was a new facility for this Licensee called the Haflinger house. LPA ensured that Administrator understood that no clients may reside at this residence until their program statement and application have been reviewed and approved. There has been no application submitted as of this time. Administrator understood and agreed that no children will reside at that house until their program has submitted the application, it has been approved, and a license has been issued. LPA reviewed four client files and five staff files, including one Administrator's, one Social Worker's, and one Facility Manager's files. LPA found that only one staff and the Administrator are acting as Facility Managers at this time, leaving the facility at times without a Facility Manager. Both the staff and Administrator have taken the Administrator's Certification course, and the staff also took an eight hour Facility Manager training course. The records were in compliance for the majority, however a few things were missing: one client out of four did not have record of a TB test being evaluated for or being given in their last medical exam. All clients that share rooms have a compatibility assessment as required however, they are based only on one child and their wants; they do not discuss/evaluate compatibility between two specific clients as required. LPA and Administrator went to the facility to review medications and medication records. All medications and medication records were in compliance. On this date, the facility is being cited for a violation of the Short Term Residential Therapeutic Program Interim Licensing Standards Section 87065(f). Two Technical Violation Advisory Notes, which are not citations, were issued as well. An exit interview was conducted with Administrator and a copy of this report along with appeal rights was left with him.

Deficiencies:
87065(f): Personnel Requirements

(f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Connie Goldie on 5/10/23 at 4:15pm.. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Stidman and Goldie met with Steve Dogan, Administrator, and inspected the facility LPAs observed the facility had three staff present with two clients present. During the inspection one staff and one client left for an outing. LPA reviewed zero child's records and three staff personnel files on site at the facility. LPA reviewed zero child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed zero children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Steve Dogan Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Steve Dogan Administrator.

met_with: Steve Dogan Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 4/5/ Licensing Program Analyst (LPA) Alyssa Burgess conducted an unannounced case management inspection at the facility regarding an incident that occurred on or around 1/25/2024, involving a former client and staff, at a Resource Family Home. LPA met with Executive Director Tegre Miles (ED) who assisted LPA with the inspection. LPA collected client and staff information from ED, Administrator Steve Dogan, and Program Director Reyes Bonilla. ED and Director will be sending LPA additional information she requested, once obtained. LPA interviewed ED. Further information is needed in order to resolve this case management. An exit interview was conducted with Administrator and a copy of this report was provided to him.

met_with: Tegre Miles & Steve Dogan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Behavioral Tech Manager Robert Smith and Facility Manager Steven Anderson, who assisted with the inspection. The purpose of this CM is to close the Case Management opened on 4/5/2024. The incident that occurred on 1/25/2024 involved staff from Mile High conducting a restraint on a child in placement at a Resource Family Home (RFH). It was alleged the restraint was conducted inappropriately, and that matter has since been referred to Solano County for investigation, as the RFH is licensed by them. LPA investigated the incident to determine how Mile High/MSK Solutions is involved in the RFH, and where the two blend together. LPA conducted this case management investigation by conducting confidential interviews with one child, one staff, the Program Director, The Executive Director, the Facility Manager, an individual associated with Mile High (P1) on 4/5/2024, 4/10/2024, 4/15/2024, 4/19/2024, 5/7/2024, and 5/23/2024, and by reviewing Incident Reports relating to the incident from both Mile High and another agency who witnessed the incident. Through investigation, LPA was informed by P1 that they are not a staff at the Mile High Mountain Top house or Legend house, but is the Executive Director's personal assistant. However, before LPA was informed of this, LPA requested P1's schedule for when they are working at the Mile High houses from the FM, who informed LPA that P1 is only scheduled at, "the Ranch," and that, "that's what [their] timesheets say." LPA requested these timesheets, however when the Director responded, LPA was informed by the Director that P1 is paid privately by him, and not through Mile High; LPA did not receive any timesheets. P1 is associated to both Mile High houses, beginning in 2021. Both the FM and P1 explained to LPA how the incident and restraint occurred. This explanation was in contrast to what was reported by witnesses. LPA was informed that the Facility Manager was called to assist P1 at the Resource Home in containing the youth in care due to the rapport FM already has with the youth, and FM responded, assisting with the restraint and de-escalation. LPA was informed by one staff, that staff from Mile High go to that Resource Home, "every week or every day," "multiple staff, a few staff from Legend house...morning shift and evening shift people." However the staff did not remember any staff names. When asked if staff leave their shift at Mile High to assist at the RFH, the staff confirmed they do and depending on C1's behaviors, they would be gone for about a couple of hours. The staff referred to the RFH as, "the Ranch." LPA learned from ED that MSK Solutions, the Licensee of Mile High homes, has another property called, "the Ranch." MSK Solutions had previously submitted intention to license that location as a facility with CCL on 10/11/2023, however then rescinded that request on 10/24/2023. LPA has visited the location and found that it is marked by a driveway arch that states, "Mile High Sky Ranch." LPA was informed that the Director lives there and it is licensed through Solano County as a Resource Family Home, where a previous client of Mile High is placed. ED informed LPA that the Director rents the home from ED, however it is not related to Mile High/MSK. LPA also learned that the clients at the Mile High houses sometimes visit the RFH to tend to the animals there. FM provided LPA with his timesheet from January 2024, obtained from a time tracking app the facility uses called a uAttend, as well as the LIC500s (Personnel Reports). FM also showed LPA the Line App which the staff and management use to communicate, and the Paychex app, which keeps staff paychecks. An office meeting will be scheduled with MSK Solutions at a future date to obtain more information regarding facility staff involvement at the RFH. An exit interview was conducted with Facility Manager Steven Anderson and a copy of this report was provided to FM.

met_with: Steven Anderson & Robert Smith


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Brittany Crass made an unannounced case management inspection at the facility and met with Facility Manager, Steven Anderson, who assisted with the inspection. LPAs and FM conducted a walk through of the home and observed no deficiencies. CCL received an incident report dated 7/1/2024 stating that clients were going to therapy at, "the Ranch." LPAs are conducting this case management to gather more information about, "the Ranch," and the therapy held there. LPA interviewed three children, one staff, and the facility manager. An exit interview was conducted with FM and a copy of this report was provided to him.

met_with: Steven Anderson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess and Regional (RM) Manager Margo Castaneda made an announced case management inspection at a separate location and met with Tegre Miles, Executive Director (ED), and Reyes Bonilla Program Director (PR) who assisted with the inspection. LPA and RM are conducting this case management to gather more information in regard to MSK Solutions' fiscal accountability. On November 14, 2024, the Community Care Licensing Division received a letter via Child and Family Services Division in regard to Solano County Behavioral Health Services Division terminating their contract with MSK Solutions, Inc.. The Sacramento Regional Office requested the last 12 months of bank statements, November 1, 2023, through November 1, 2024, for all their accounts pertaining to Mile High Legend Home Facility #487005982, Mile High Mountain Top Facility # 487005059, and any other accounts associated with MSK Solutions, Inc. This will be provided to CCL by 12/10/2024. LPA and RM interviewed ED and PD. An exit interview was conducted with ED and PD and a copy of this report was provided to them.

met_with: Tegre Miles & Reyes Bonilla


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Staff Tom Arriola and Jose Reyes. Facility Manager Steven Anderson arrived to further assist LPA. CCL received an incident report dated 11/25/2024, sent to CCL on 11/26/2024. LPA is conducting this case management to attain more information. LPA interviewed one client, staff, and Facility Manager. There were no other clients present. Further information is needed to resolve this case management. An exit interview was conducted with FM and a copy of this report was provided to him.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with staff Jose Reyes and Administrator Steve Dogan who assisted LPA with the inspection. CCL received an incident report dated 11/25/2024, sent to CCL on 11/26/2024. This Case Management was opened at the facility on 12/11/2024. LPA reviewed this incident by conducting confidential interviews with the child involved, the Facility Manager, and the Administrator between 12/11/2024 - 1/7/2025. Based on the interviews, LPA found the accusation made in the incident report was false, as confirmed by the child. This case management is now closed, no further action necessary. An exit interview was conducted with Administrator and a copy of this report was provided to him.

met_with: Jose Reyes & Steve Dogan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Orlando Areizaga made an unannounced annual inspection at the facility and met staff Jose Reyes and Administrator Steven Anderson who assisted with the inspection. LPAs conducted a walk through of the facility with staff and Administrator. LPAs observed: three client bedrooms, two pantries, one hall closet, one kitchen, two living rooms, a staff office/therapy office space, the backyard, a laundry room, and the garage. The client bathroom did not have paper towels/towels. There was no sign posted denoting the hot water for the coffee maker. The floors and surfaces throughout the facility were sticky. The area above the stove on the cabinets and ceiling had crease/grime. The facility had a limited variety of non-perishable food for 7 days for 5 clients. LPA advised to obtain more variant non-perishable foods. There was a low amount of fresh vegetables. Two of the client dressers were in disrepair. The medication was inaccessible as required. The hot water measured at 112.4 degrees Fahrenheit, which is within the required temperature range of 105-120. There was a working carbon monoxide detector. LPA's inspected the facility van and saw that it was in working condition with fair tires, no problem indicator lights, and working seat belts. The first aid kit was present and had all required elements. LPA Areizaga took photos of facility on state-issued cellphone. LPA interviewed two clients. The facility has a client register as required, however it needed to be updated as they recently got a new client in the house. Client cash resources/records were inaccessible as required. There was no planned activity schedule. The items planned on the menu were not present in the facility in these cases: Today lunch planned was salad with grilled chicken. However, there was only one small romaine heart and the chicken was still frozen, for tomorrow: no bagels were present in the house, and no ramen, which was planned for tomorrow's lunch. For Thursday there was no pancake mix, which was scheduled. One staff mentioned having PB&J sandwiches planned, however there was no bread. FM stated that he would be going shopping right now and the usual staff who buys the food was off. Client cash resources are maintained in a binder, kept locked in a closet. One client's allowance was incorrectly documented as having had no previous balance, then was issued $20 on 4/4/2025, marked as withdrawn $20, and then marked as having a $20 balance. However, there was no $20 in the binder. Admin stated the record was incorrect and should be a $0 balance. Administrator will have the record corrected and the client re-sign for the correct amount when they return from school on today's date. The Board meets quarterly as required. LPAs could not complete the inspection on this date, and will return on another date to complete the annual inspection. On this date, the facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, Section 80087(a). Technical Violation Advisory Notes, which are not citations, were also issued. Additionally, LPA provided Administrator with the letters of revisions needed for Mile High's Program Statement and Plan of Operation update. The due date for revisions is 5/21/2025, and LPA scheduled a date to meet with the agency with Administrator Steven Anderson to go over any questions they have, for 4/21/2025 at 10: AM. A Microsoft Teams meeting was sent to Administrator for that date and time. An exit interview was conducted with Administrator and a copy of this report and appeal rights was provided to him.

met_with: Jose Reyes, Steven Anderson, Corri Collins


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
At 9: AM, Licensing Program Analysts (LPA) Alyssa Burgess and Orlando Areizaga made an unannounced annual continuation inspection at the facility's Administrative Office where their files are stored. No one answered the door and LPA called Administrator Steven Anderson, who stated he will be on his way. Later, LPAs checked the door again and Office Assistant Corri Collins answered, stating LPAs could not access the office, as there would be a meeting happening soon. LPA informed OA that they need to complete the annual and as the files are located at the office, they are there. OA informed LPA that a supervisor is not available, and LPAs may not use any place in the office. LPM Jodean Hall called Administrator to help facilitate the annual inspection. Administrator arrived and LPA provided him a list of all information needed to complete the annual. LPAs took a break to allow Administrator time to gather the documents and arrived at the Legend Home facility at 12: PM to continue the annual as agreed. At 12: PM Administrator arrived with the documents. LPA was provided the licensing documents retained for the past three years. The most recent report presented was dated 5/10/2023. The facility did not maintain Licensing Reports for the past three years as required. There was no manual restraint log. The facility is conducting disaster drills on a monthly basis, however does not conduct them at least once per shift, per six months. The Administrator brought staff files for staff from the Mountain Top house and needed to return to the Admin office to get Legend Home staff files. LPAs reviewed one Administrator file and one Clinician file. Once Administrator returned with the correct files, LPAs reviewed one Facility Manager file, and two staff files, finding: All staff are fingerprint cleared and associated as required. The Administrator and Clinician meet all requirements. The Clinician's (MH1) CPR/First expired 11/30/2024. On 4/7/2025 and today 4/8/2025 when LPAs arrived at the facility, S1 was the only staff present, who does not meet the education and experience requirements of a Facility Manager. There were no qualified Facility Managers present until Administrator arrived to assist. LPAs advised Administrator about the exception request process. All staff reviewed met the annual training requirements. LPAs reviewed four client files and found: The Needs and Services Plans (NSPs) did not include any information about clients having the need to be routinely searched. Through interviews and based on LPA observation, clients get searched with a metal detecting wand, and have their possessions searched, when they enter the facility as a standard practice. This is a violation of the clients' right to be free from unreasonable searches. The two clients observed to be searched (C1 and C2) on 4/7/2025, and C2 on 4/8/2025 had no indication in their NSP for the authorization of routine searches. Administrator stated C1 and C2 had no need to be wanded/searched. Administrator informed staff during this inspection. There was not a staff person designated to facilitate/plan the planned activities and there was no planned activities calendar. LPA was not provided a current record of mental health services provided to the clients for the past 12 months despite requesting one. A record of mental health services was provided to LPA on 3/7/2025 for an unrelated reason, and today, LPA was informed that is the record she should use, as directed by Interim Executive Director Jamek Johnson. The record shows that all clients have not received "psycho therapy" since the end of January 2025. LPA interviewed one staff and one Administrator on this date. LPA found they were knowledgeable about their roles and the clients. LPA advises for some refreshers on the mandated reporter process. One client's JV223 dated 6/24/2024 is expired. There is an email dated 5/8/2024 requesting review for renewal, however no other follow-up included in the file. Administrator is unsure if the client no longer takes psychotropic medications because they were refusing them, or because the JV223 expired. LPA issued an advisory note to inform LPA of the reason. On this date the facility is being cited for sections of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 5, Sections 87072(c)(10), 87065(f), and 87089.1(g) on the attached LIC809-Ds. LPA also issued Technical Violation advisory notes, which are not citations. An exit interview was conducted with Administrator and a copy of this report, confidential names list, and appeal rights were provided to him.

Deficiencies:
87065(f): (f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present
87089.1(g): Deficient Practice Statement
1
2
3
4Based on records reviewed, the licensee did not comply with the section cited above when the records provided did not demonstrate that clients have been provided at least monthly consultation with a psychiatrist, or clinical psychologist, or licensed clinical social worker regarding the program of services, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
1
2
3
4BY POC due date, the facility will submit to CCL a complete record of all mental health services each client has received since January 1, 2025.

title:
Mental Health

(g) A short-term residential therapeutic program providing care and supervision to children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered shall make provision for at least monthly consultation from a psychiatrist, or clinical psychologist, or licensed clinical social worker regarding the program of services, or more often as appropriate to the needs of the child or nonminor dependent.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Orlando Areizaga, and Licensing Program Manager (LPM) Jodean Hall met with Administrator Steven Anderson via Microsoft Teams. The purpose of this visit was to provide any technical assistance needed regarding the facility's Program Statement and Plan of Operation updates, detailed in the revisions letter provided to the facility on 4/7/2025. During the review it was agreed upon that the letter is understood, and Administrator will reach out if any additional guidance is needed. The revisions are due to CCL by 5/21/2025. An exit interview was conducted with Administrator and a copy of this report was provided to him. Administrator will send a signed copy back to CCL.

met_with: Steven Anderson,


summary: Facility Evaluation

raw_content:
Narrative:
On May 20, 2025, at approximately 9: AM, Licensing Program Analyst (LPA) Orlando Areizaga made an unannounced inspection to the Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a case management inspection. LPA Areizaga met with Administrator, Steven Dogan who granted LPA access to the facility. On May 19, 2025, LPA Areizaga received an incident report stating the glass on the sliding glass door in the living room near the kitchen was shattered on Sunday, May 18, 2025. During today's inspection, LPA observed that the slider door was boarded on the interior and exterior of the door. LPA also confirmed that a work order was submitted by the licensee for repair. It was noted that the outside contractor will be on site on Wednesday, May 21, 2025, around 1: PM to 3: PM to provide an estimate. Once the estimate is received, the licensee will pay for the repair, submit a copy of the receipt via text or email to LPA Areizaga, and notify LPA once the repairs have been completed. An exit interview was conducted, and a copy of this report was emailed to Administrator, Steven Dogan.

met_with: Administrator,Steven Dogan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with staff Kareem Dupree, who assisted with the inspection. On 2/3/ The Licensee, MSK Solutions, was informed by the Department's Audit Section that they will be receiving a solvency audit for both of their licensed STRTPs: Mile High Legend Home #487005982 and Mile High Mountain Top #487005059. The Department informed the Licensee of the reason for the audit, and all required information needed to perform the audit. The due date for submission of the required information was 3/3/2025. On 3/7/2025, the Department followed up with the Executive Director (ED) Tegre Miles regarding not having received the required documents to conduct the audit, nor a request for an extension of time. On 3/12/ ED responded with their concerns, and that they intended to finish everything by the coming Friday (3/14/2025). The Department responded to ED addressing their concerns and granting an extension until 3/14/2025. Failure to submit the required documents would result in the completion of the audit, documenting noncompliance with the Department's Inspection Authority. On 3/17/2025, ED responded to the Department with their concerns, however no documentation was provided. For the related citations and repeat civil penalty, please refer to the 809 dated 5/8/2025 under the Mountain Top facility #487005059. An exit interview was conducted with staff and a copy of this report was provided to him.

met_with: Kareem Dupree


summary: Facility Evaluation

raw_content:
Narrative:
On October 9, Licensing Program Analyst (LPA) Sarina Buchannan arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management inspection. LPA was greeted by Jamek Johnson, Executive Director, who granted LPA access. LPA conducted a tour of the inside and outside of the facility where LPA observed the following deficiencies. Windows do not have screens allowing flies and other insects into the facility. One clients bedroom door is covered in a soap and also has a small hole to the right. There is one hole in the laundry room door. One clients bedroom window has a hole in the window sill. One clients dresser is missing a drawer. Trash cans in common areas are missing lids. The facility is being issued a technical violation for Buildings and Grounds. (See LIC TV) This case management will remain open, until the facility provides proof it is in full compliance. An exit interview conducted and a copy of this report was left with licensee.

met_with: Jamek Johnson, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On November 5, 2025, at approximately 11: AM, Licensing Program Analyst (LPA) Orlando Areizaga arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of closing a Case Management inspection. LPA was greeted by Jamek Johnson, Executive Director, who granted LPA access. On October 9, Licensing Program Analyst (LPA) Sarina Buchannan arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management inspection. LPA was greeted by Jamek Johnson, Executive Director, who granted LPA access. LPA conducted a tour of the inside and outside of the facility where LPA observed the following deficiencies. Windows do not have screens allowing flies and other insects into the facility. One clients bedroom door is covered in a soap and also has a small hole to the right. There is one hole in the laundry room door. One clients bedroom window has a hole in the window sill. One clients dresser is missing a drawer. Trash cans in common areas are missing lids. LPA received photo proof of the corrections from Jamek on October 23, 2025 via email. This case management is close. No further follow up is needed. An exit interview conducted and a copy of this report was left with licensee.


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
During the investigation LPAs obtained inconsistent statements during the investigations process about staff not being properly trained to care for and supervise minors. Five of 9 interviews and records review confirmed staff feel comfortable and properly trained to care for minors. It was confirmed through confidential interviews that staff receive on-going job training and additional training monthly. In addition, LPAs obtained inconsistent statements during the investigations process about staff not providing adequate food services and ensuring an adequate supply of food. Five of 9 interviews confirmed the facility provides three main meals and always has snacks available. It was also confirmed that the facility managers do grocery shopping at least once per month. Confidential interviews confirmed that facility managers do shopping based on the number of residents that are in placement. Lastly, LPAs obtained inconsistent statements during the investigations process about staff not providing compensation for work provided. Five of 9 interviews confirmed staff do not offer alternative compensation for residents. Confidential interviews confirmed only behavioral technicians and managers are allowed to offer compensation for residents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur therefore the allegations are unsubstantiated. An exit interview was conducted, and Appeal Rights were discussed with Administrator, Tim Delaney. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On December 30, 2025, Licensing Program Analyst (LPA) Orlando Areizaga conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Administrator, Tim Delaney and was granted entry. Prior to the meeting, LPA Buchannan initiated the complaint investigation on October 9, 2025. No deficiencies were cited during that inspection. LPA Buchannan requested the following documents Menu for month of October, Staff Roster, Client census, Client Face Sheet, Staff Schedule, Staff Contact Information, Client and Needs and services, client finance book, and staff training. 9 confidential interviews were conducted between October 2025 and December 2025 by LPAs Areizaga and Buchannan. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Orlando Areizaga LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 12/30/2025

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On June 19, 2025, at approximately 11: AM, Licensing Program Analyst (LPA) Orlando Areizaga made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a case management. LPA Areizaga met with Administrator, Steven Dogan who granted LPA access to the facility. On June11, LPA Areizaga received an Incident Report (IR). The date the IR occurred was June 2, 2025. Based on file reviews, LPA Areizaga confirmed that the STRTP did not meet the reporting requirements, as no 24 hour notification nor a 7-day follow up report was submitted to the department at the time the STRTP was aware of the incident. The STRTP is being cited per 80061(b) Reporting Requirements for failure to report an incident on the LIC 809-D. This is a potential Health, Safety, and Personal Rights risk to children in care. This report was discussed with Administrator, Steven Dogan and a copy of this a copy of the report and appeal rights were printed and left at the facility.

Deficiencies:
80061(b): Upon the occurrence...a report shall be made to the licensing agency... next working day...In addition...report...shall be submitted...seven days following the occurrence of such event.

title:
1
2
3
4
5
6
7Reporting Requirements


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 5, 2025, at approximately 11: AM, Licensing Program Analyst (LPA) Orlando Areizaga made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a case management. LPA Areizaga met with Jamek Johnson,Executive Director who granted LPA access to the facility. On October 25, 2025, LPA Areizaga received an Incident Report (IR). The date the IR occurred was October 25, 2025. On November 3, 2025, LPA emailed Staff, Debbie CoffeyRush for more information. Debbie stated the following, "I had completed this last week with the others, however after receiving your email I found in my drafts and take full responsibility for this error. This was my fault and no one else's error. Please accept my apologies again Orlando. Reprimand me accordingly." Based on a file review and conversation with staff, LPA Areizaga confirmed that the STRTP did not meet the reporting requirements, as no 7-day follow up report was submitted to the department at the time the STRTP was aware of the incident. The STRTP is being cited per 80061(b) Reporting Requirements for failure to report an incident on the LIC 809-D. This is a potential Health, Safety, and Personal Rights risk to children in care. It was noted that the STRTP was cited for a Type B violation on June 19, 2025, for reporting requirements. A civil penalty in the amount of $250.00 has been assessed for a repeated violation of reporting requirements within a 12-month period An exit interview conducted and a copy of this report was left with licensee.

Deficiencies:
80061(b): Upon the occurrence...seven days following the occurrence of such event.

title:
1
2
3
4
5
6
7Reporting Requirements


summary: Facility Evaluation

raw_content:
Narrative:
On December 30, 2025, at 12: PM, Licensing Program Analyst (LPA) Orlando Areizaga arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management inspection. LPA was greeted by Administrator, Tim Delaney, who granted LPA access. LPA conducted a tour of the interior and exterior of the facility. LPA observed the following deficiencies: The thermostat was off. The first floor of the facility was colder than F degrees. The exterior perimeter fence has two missing posts. Bedroom 1 missing blinds During the inspection, the facility has submitted maintenance requests. The facility is being cited for Building and Grounds 80087(a) on the LIC809D This case management will remain open, until the facility provides proof it is in full compliance. An exit interview conducted and a copy of this report was left with licensee.

met_with: Administrator, Tim Delaney


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On January 16, 2026, at approximately 10: AM, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management deficiency. LPA and LPM were greeted by Administrator, Tim Delaney, who granted LPA and LPM access. On December 30, 2025, LPA opened a complaint and requested the following documentation: Staff Roster, Client census, Client Face Sheet, Staff Schedule, Staff Contact Information, Client and Needs and services, and staff training. It was noted on the LIC 9099 and via email sent on December 30 that the STRTP shall send LPA the documents via email by December 30, 2025, by 5: PM. The STRTP did not meet the deadline of December 30, 2025, by 5: PM. However, the STRTP did send the documentation on December 31, 2025, at 9: AM. The STRTP is being cited a Type-B Violation per CCR Client Records 80070(d) on the LIC 809-D. Exit interview was conducted, with Title and Name. A copy of this report was left at the facility.

Deficiencies:
80070(d): All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...

title:
1
2
3
4
5
6
7Clients Records


summary: Facility Evaluation

raw_content:
Narrative:
On January 16, 2026, at approximately 10: AM, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management deficiency. LPA and LPM were greeted by Administrator, Tim Delaney, who granted LPA and LPM access. LPA and LPM conducted a tour of the interior and exterior of the facility. LPA and LPM observed the following deficiencies: Two (2) fire extinguishers were not serviced. Last services 12/5/ Activity calendar did not have six (6) months work of calendars The facility is being cited for Interim Licensing Standards (ILS) Planed Activities87079(e)(1) and California Code of Regulation Title 22 (CCR) Fire Clearance 80020(a)(1) on the LIC809D This case management will remain open, until the facility provides proof it is in full compliance. An exit interview conducted and a copy of this report was left with licensee.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Connie Goldie on 02/08/2024 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Goldie met with Steve Dogan, Program Administrator and inspected the facility inside and out. LPA reviewed one child's record. LPA reviewed three staff personnel files on site at the facility. LPA reviewed three of child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one child currently prescribed psychotropic medication. During the inspection the LPA observed one type B deficiency (see attached 809D). LPA Goldie cited Interim Licensing Standards Needs and Services Plan 87068.3(a). Plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Steve Dogan, Program Administrator.

Deficiencies:
84068.3: 1
2
3
4
5
6
787068.3(a) Modification to the Needs and Services Plan The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following

met_with: Steve Dogan Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 02/02/2026, this document is being amended by Licensing Program Analysts, Orlando Areizaga and Sara Luman-Gonzalez. On 1/30/2026, LPA Areizaga issued a techinical violation for client records not being accessible .This technical violation is being rescinded. See the case management dated 02/02/2026 for Case Management deficiency issued pertaining to Children's records regulation violation.


summary: Facility Evaluation

raw_content:
Narrative:
On February 2, 2026, at approximately 11: AM, Licensing Program Analyst's (LPAs) Orlando Areizaga and Sara Luman-Gonzalez arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a case management for observations made during an inspection on January 30, 2026. LPA's were greeted by Administrator, Tim DeLaney, who granted LPA's On January 30, 2026, at approximately 10: AM, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie arrived unannounced at the above facility. During the visit, LPA and LPM asked for client's file. LPA attempted to contact Executive Director, Jamek Johnson and Administrator, Tim Delaney but they not answer. LPA then called Office Manager, Corrie Collins for documentation as she previously has provided LPA facility records. Corrie redirected LPA to Mile High Executive Staff to make request. It was noted that the facility manager and the facility administrator did not have direct access to the current client files. It was also noted that the facility's client's binder was missing context to a clients file. Per the visit on January 30, 2026, LPA is citing for the California Code Regulations (CCR) Clients Records 80070(a) on the LIC 809-D for not maintaining a complete and current client record in the facility. A copy of this report and LIC 809-D were discussed with, Administrator, Tim DeLaney and left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jean Stidman and Licensing Program Manager (LPM) Connie Goldie on 03/02/2026 at 9:30am This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Stidman and LPM Goldie met with Tim Delaney, Administrator and inspected the facility inside and out. LPAs reviewed two staff personnel files on site at the facility. LPAs interviewed two staff on site to discuss the facilities policies and procedures of operation. LPAs did not interview any children currently prescribed psychotropic medication nor review their file as they are not dependents. During the inspection the LPA observed one Type B deficiency (see attached 809D). LPA Stidman cited California Interim Licensing Standards 87070(b)(14). The plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Tim Delaney, Administrator

met_with: Tim Delaney, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
During an unannounced Inspection conducted by Licensing Program Analyst (LPA) Jean Stidman and Licensing Program Manager (LPM) Connie Goldie it was observed two smoke detectors in bedrooms numbered one and two are missing the battery and the pin to the fire extinguisher in the kitchen has been pulled. Facility cited violation of California Code of Regulations, Title 22, Division 6, regulation 80087(a) Buildings and Grounds. LPA provided a copy of this licensing report to Tim Delaney, Administrator


raw_content:
Narrative:
During the investigation LPA obtained inconsistent statements during the investigations process about staff communicating in an inappropriate manner towards a minor. 2 of 3 interviews confirmed staff did not speak inappropriately to the youth in care. It was noted during a confidential interview that the staff was speaking calmly while the incident was in progress. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation is unsubstantiated. An exit interview was conducted, and Appeal Rights were discussed with Administrator, Tim Delaney. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On April 1, 2026, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met withAdministrator, Tim Delaney and was granted entry. Prior to the meeting, LPA initiated the complaint investigation on December 30, 2025. No deficiencies were cited during that inspection. LPA requested the following Staff Roster, Client census, Client Face Sheet, Staff Schedule, Staff Contact Information, Client and Needs and services, and staff training. 3 confidential interviews were conducted between December 2025 and March 2026 by LPA Areizaga. Lastly, it was noted that LPA could not confirm the allegation with the Reporting Party (RP) and County Social Worker (CSW) due to multiple failed attempts to contact. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Orlando Areizaga LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 04/01/2026


raw_content:
Narrative:
During the investigation process, LPA obtained inconsistent statements about facility is in financial distress. Seven of 9 interviews confirmed the facility does not exhibit financial distress. It was noted during confidential interviews that the facility pays their staff in full, has cash resources for facility damages and facility routine maintenance. In addition, LPA also obtained inconsistent statements during the investigations process about youth activities are being impacted by financial mismanagement. It was also noted in 7 of 9 interviews that the client's activities are not being impacted. It was noted during confidential interviews that clients have opportunities to attend outings which are paid for by the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur therefore the allegations are unsubstantiated. An exit interview was conducted, and Appeal Rights were discussed with Administrator, Tim Delaney. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On April 1, 2026, Licensing Program Analyst (LPA) Orlando Areizaga conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Administrator, Tim Delaney and was granted entry. Prior to the meeting, LPA initiated the complaint investigation on January 16, 2026. No deficiencies were cited during that inspection. LPA requested the following board meeting minutes for a year, LIC 9165, activity calendar for the last six months, LIC 500, LIC 9020, facility financial records for client outings for last 6 months, staff pay records timesheets and paystubs for 6 months, staff training logs, and two client's treatment plans. 9 confidential interviews were conducted between December 2025 and March 26 by LPA Areizaga. Lastly, it was noted that LPA could not confirm the allegations with Client 2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Orlando Areizaga LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 04/01/2026


raw_content:
Narrative:
During the investigation LPA obtained inconsistent statements during the investigations process about staff handling client roughly. Six of 7 interviews confirmed staff did not physically touch minor during the incident. It was noted during confidential interviews that clients have not been physically harmed while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation is unsubstantiated. An exit interview was conducted, and Appeal Rights were discussed with Tanisha Walters, Behavior Technician Manager. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On April 20, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Tanisha Walters,Behavior Technician Manager and was granted entry. Prior to the meeting, LPA initiated the complaint investigation on January 30, 2026. No deficiencies were cited during that inspection. LPA requested the following LIC 500, LIC 9020, Client Face Sheet, Staff Schedule, Staff Contact Information, Client and Needs and services, and staff training. 7 confidential interviews were conducted between January 2026 and April 2026 by LPA Areizaga. Lastly, it was noted that LPA could not confirm the allegations with Reporting Party. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Orlando Areizaga LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 04/20/2026


facility_name: MILE HIGH MOUNTAIN TOP

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program analyst (LPA) Jennifer Baca arrived at the agency to conduct an unannounced complaint inspection on 9.93.2022 at 10: Am. LPA Baca spoke with Steve Dogan , Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA informed agency staff this case was investigated by LPA Baca. The initial 10-day complaint investigation inspection was conducted at the agency on 3.22.2022, by LPA Burgess. Documents received for staff included the following: Staff roster, Staff phone numbers and Staff schedule. Documents regarding foster Youth included the following: Medical records and school information. Interviews were conducted with Administrator 9.2.2022, Staff 1 on 9.02.2022, Director on 9.7.2022, FY1 on 9.8. LPA was unable to interview Reporting party or the Police officer after multiple attempts of contacting and leaving a return number. During the investigation, LPA Baca investigated the complaint staff did not prevent minors from engaging in inappropriate behavior. Interview with Admin and Staff 1 stated that the two youths that were accused of injuring FY1 had been awol at the time of the incident, and there was no youth at the facility at the time of the incident. Interview with Director stated that after an internal investigation he found that FY1 was the only youth at the facility at the time he AWOLed from the facility. Interview with FY1 stated that he refused to talk to LPA because the incident happened so long ago.As a result of the investigation and interviews conducted, the allegation staff did not prevent minors from engaging in inappropriate behavior. This allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Jennifer Baca LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Steve Dogan, Administrator


raw_content:
Narrative:
There were also multiple incidents in which one client was sexually inappropriate with another client by flirting, trying to show their genitals, dry-humping, and more. Interviews revealed that for the majority of the time, staff did intervene to stop this from occurring, however some clients stated that it was not at all times. One staff stated these incidents sometimes occurred quickly and out of view of staff. Clients stated they would often rough-house with each other, and some stated staff would tell them to stop. In one incident, a client allegedly poked another client in the anus. When staff became aware of the allegation, it was immediately reported and investigated by the facility. After the facility investigated, they issued a discharge notice for the client on an emergency basis to keep the other clients safe. Based on interviews LPA found there was a clear pattern of one client being physically inappropriate and aggressive with other clients in the home, and while action was taken with the aggressing client it is unclear if action could and should have been taken sooner, based on the information provided. During interviews with seven clients, six staff, the Clinician, the Administrator, and the Executive Director, LPA was informed that the house is clean. Clients have chores and do them daily. If a client does not do their chore, staff clean up after the clients or incentivize other clients to cover the chore for more points. Additionally, all individuals interviewed except for one stated that a mess does not last more than a day, and most of them stated it lasts less than hours. One client stated it might last up to a day and a half. One client stated that after a client was in the bathroom sometimes there would be pubic hair, feces, urine, and soap. One staff stated the floors are sticky sometimes. LPA has visited the facility unannounced on many occasions over years, and has not observed the home to be messy or dirty. (continued)... During interviews with clients, staff, a witness, Administrator, and the Executive Director, LPA learned that a client had their money stolen on at least one occasion, but possibly more than once. The client stated the money was locked up with staff and it went missing. Other clients stated another client stole the money, or that they heard that it was a staff. The Administrator stated it was looked into and it was unclear, as sometimes the client kept their belongings in their room instead of locking it up, as well as brought money in without telling staff how much there was. The Executive Director was unsure of the outcome and thought that management had figured it out, as well as stated that if the money was lost by staff, then it would be replaced. All clients stated they are allowed to lock their personal belongings up with staff for safe-keeping, and some choose to do so. Staff repeatedly encouraged the client to safeguard their money. One staff stated they brought up the missing money during management meetings, and it was brushed off. Additionally, in LPA's review of the client's allowance sheets, there were some errors and entries that were unclear. LPA brought this to the attention of the ED, who discussed this with Administrator. In another visit to the facility for an annual on 3/6/2024, LPA observed a random sample of a client's allowance sheet in which LPA again observed errors. LPA addressed this with the Administrator during that inspection. Based on conflicting information, and lack of information, it is unclear if in this instance the facility failed to safe-guard the client's money. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with FM and a copy of this report and appeal rights were provided to him.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. LPA investigated this complaint by reviewing client allowance records and conducting interviews with seven clients, six staff, a witness, the Administrator, the Clinician, and the Executive Director on 12/29/2023, 1/24/2024, 4/5/2024, 4/9/2024, 4/15/2024, 4/16/2024, 4/17/2024, 4/19/2024, and 4/22/2024. During interviews with clients, staff, a witness, Administrator, and the Executive Director, LPA learned of various incidents involving the clients which were inappropriate in nature. In one incident, two clients were fighting which resulted in one client being bitten by the other one, and going to the hospital. LPA was informed of mixed details during interviews. A witness stated the staff on shift responded immediately and appropriately to the fight. One client stated it took about five minutes for staff to respond. Another client stated when one client assaulted the staff, the staff left the situation, however the staff denied this. All interviews stated staff intervened and separated the clients. After this incident, the client was given a room change to keep the other client safe. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 05/06/2024


raw_content:
Narrative:
During interviews, one staff stated that due to the facility's consequences/level structure, it does not meet the clients' mental health needs as a therapeutic environment. One client felt the facility gives, "shitty," therapy, however they met with the therapist twice a week. The client refused to see the facility psychiatrist, and saw their Kaiser psychiatrist instead. LPA was informed by the Clinician and one client that this client sometimes refused to engage or participate in the mental health services offered to them by Mile High. Another client stated they did get therapy at the facility, but stated it was not all that they needed. When asked what else they needed, the client stated they did not know and it was only something, "someone," told them. One client stated there are Behavioral Techs at the facility but all they want to do is take them to the library and not talk to them, but the client also stated they refused to meet with mental health staff to have their mental health needs met, so it is unclear if they actually did not meet the client's needs. During other interviews with all other clients, they confirmed their mental health needs are met. There are Behavioral Techs who are in the facility daily to meet with the clients about their mental health and clients meet with the Clinician at least twice a week. Additionally, LPA was informed by the Clinician that a psychiatric nurse practitioner comes to the facility to assess the clients' medications and make recommendations. The facility has a psychiatrist as well who diagnoses clients and prescribes them medications. Based on LPAs interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. On this date the facility is being cited for a violation of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 5, Section 87089.1(a). An exit interview was conducted with FM and a copy of this report and appeal rights were provided to him. In an interview with another client, they stated that Admin has a, "slick mouth." When asked why they feel that way, they said because Admin told them, "if you keep acting up you're not going to get your full allowance," and, "always yelled." LPA clarified the meaning of yelling with the client, who maintained that Admin yelled, however gave no description of yelling. In another client interview, LPA was informed that Admin, "yells all the time." The client stated Admin yelled at a client to get out of another client's room. When clarification questions were asked, the client determined Admin was not yelling, only raising his voice. The other clients stated Admin does not yell at them. Staff informed LPA that Admin is the one to address consequences with the clients. The Program Director explained that because of this he gets a, "bad rep," but he is not yelling. LPA was informed that Admin has a, "stronger," voice and some clients will say he is yelling, "but he is just being firm." All staff interviewed denied that Admin yells at the clients. LPA was informed by one client that Executive Director (ED) Tegre Miles has cussed at them, telling them, "you're on bullshit." Another client stated ED yells at the clients, but it is only to get his point across and not to scare them. The other clients denied ED yells at them. LPA learned from the Program Director that ED is also the one to address the clients' behavior and consequences with them. LPA was informed that it is true that ED could have a softer approach with some of the more, "sensitive," clients, and they, "could see how some kids can perceive some things negatively, though it is never inappropriate." LPA was informed that ED will explain to clients the consequences of their actions and they won't like it. One staff stated that ED speaks to the clients, "very bold, disrespectful, and yelling and cursing." When asked for an example of this, the staff stated ED says, "I don't give a shit," "I don't give a damn." The staff stated however, that it is nothing abusive. Another staff stated ED has said to clients before to, "cut this bullshit out." When asked about cussing to the clients, ED stated that he sometimes does talk to the clients in their language, or paraphrases what they say to him. ED stated he does not yell at the clients, but is a straight-talker with them. Based on this information it is not clear if ED and Admin do yell at the clients, or if it is a perception by the clients due to the nature of the conversations, the language used, and/or the natural voices of the ED and Admin. During interviews with seven clients, six staff, the Clinician, the Administrator, and the Executive Director, LPA was informed that the house is clean. Clients have chores and do them daily. If a client does not do their chore, staff clean up after the clients or incentivize other clients to cover the chore for more points. Additionally, all individuals interviewed except for one stated that a mess does not last more than a day, and most of them stated it lasts less than hours. One client stated it might last up to a day and a half. One client stated that after a client was in the bathroom sometimes there would be pubic hair, feces, urine, and soap. One staff stated the floors are sticky sometimes. LPA has visited the facility unannounced on many occasions over years, and has not observed the home to be messy or dirty. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. LPA is issuing an advisory note to address the language used by the Executive Director with the clients. An exit interview was conducted with __ and a copy of this report and appeal rights were provided to __.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. LPA investigated this complaint by reviewing CFT notes and conducting interviews with eight clients, six staff, a witness, the Administrator, the Program Director, the Clinician, and the Executive Director on 12/29/2023, 1/24/2024, 4/5/2024, 4/9/2024, 4/15/2024, 4/16/2024, 4/17/2024, 4/19/2024, and 4/22/2024. One of the clients had been experiencing an increase in mental health crises and adverse behaviors. An emergency Child & Family Team Meeting (CFT) was scheduled to address this. After the emergency CFT was held on 2/5/2024, LPA reviewed the notes and found that neither the client's safety, nor the client's mental health concerns were discussed in the CFT, for which the purpose of the meeting was. Instead, only school and placement plans were discussed. When LPA asked Admin and Program Director why this was, they were unsure. LPA instructed Admin and PD to ensure another CFT is called to address these areas of concern. Both agreed to this, and the meeting occurred on 2/13/2024 in which the client's mental health needs and safety planning were discussed. A safety plan was created and the client was moved to Mile High's other house to improve the client's mental health. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 05/06/2024


raw_content:
Narrative:
Review of the police reports revealed: LE arrived and observed ED and FM restraining C1 on the bed. C1 informed LE that ED pinched C1 during the restraint and twisted C1's arms, when he came in from the window. C1 also also reported ED was digging ED's elbow into C1's back. LE did later observe on C1, "fresh abrasions with bruising and redness to [C1's] left forearm, which is the side ED restrained C1 on," and where it was alleged that ED pinched C1. Interviews with the children revealed: one child stated they did not see the restraint but heard, "just a bunch of shouting and yelling." The child denied that any staff have hurt any child at the facility. One child stated ED and FM came into the room saying nothing and just restrained C1 on a dresser and then on a bed where C1 was on their stomach for a while until C1 stated they could not breathe. Then ED and FM flipped C1 over, and picked C1 and, "put [C1's] head against the wall." The child stated ED told LE that they were restraining C1 due to them spitting on ED and FM. C1 admitted to LPA they had been on the roof out of boredom, then went to another client's room waiting for the ED and FM to arrive. C1 explained that ED and FM pulled C1 off of the bed to restrain them by taking their arms up and putting them on the bed on their stomach, "to where I couldn't breathe." C1 explained then ED was, "talking crap," to them and pinching them on their arm, which left bruises. FM was not doing anything that was hurting C1. The restraint ended when the police arrived. Interviews with staff revealed: one staff did not witness the restraint as they were supervising the other clients. One staff stated it was when C1 kicked out at ED/FM that they initiated the restraint. The staff denied that anyone fell and that C1 was not put on their stomach. FM informed LPA that when he and ED arrived, they entered the room, asked the other client to leave and C1 was, "talking trash, doing threatening (gestures), so we went into the restraint." C1 was being threatening by, "looking like [C1] was going to swing at [ED]." Once on the bed, C1 was, "just sitting there, no struggle, just verbal threats," but they continued the restraint until LE arrived. FM confirmed they advanced on C1 in the room, and C1 was only making verbal threats. ED informed LPA he and FM attempted to verbally de-escalate C1 while C1 was sitting on a bed. C1 became upset and swung their fist out which is when the restraint was initiated, and they stood C1 up against a dresser. They moved to the bed and C1 was still making verbal threats until police arrived after about 15 to 20 minutes. LE arrived and took over. ED denied C1 was ever on their stomach, denied he was upset, and denied that he was hurting/pinching C1 during the restraint. FM and the staff denied FM or ED were rough with C1. FM admitted other things could have been tried before restraint. ED stated he could not evade because he did not have the space. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Admin, and a copy of this report and appeal rights were provided to you.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA investigated this complaint by reviewing two police reports, the facility incident report, staff Emergency Intervention training records, and by conducting confidential interviews with three children, two staff, the Executive Director (ED), and the Facility Manager (FM), on 3/14/2024, 4/9/2024, 4/10/2024, 4/16/2024, 4/17/2024, and 5/6/2024. The facility incident report described the client (C1 - See Confidential Names List dated 7/10/2024) having been engaging in dangerous behavior of getting on the roof in the rain from their bedroom window, moving their bed into the hallway, trying to get into the attic, and throwing things at staff. ED and FM were called to assist. When ED/FM arrived, they saw C1 hanging outside of his window and entered the room. Then, C1 aggressively approached ED and FM, "within 3 feet," and had closed fists. That is when ED and FM placed C1 in a restraint. A struggle ensued and at one point they fell to the bed. ED and FM transitioned to a seated restraint with C1 on the bed and Law Enforcement (LE) was called. Once LE arrived, C1 was released from the hold and LE took over. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 07/10/2024

met_with: Steve Dogan


raw_content:
Narrative:
Interviews with staff and clients informed LPA that the client (C1 - See Confidential Names List dated 5/7/2025) struggled with substance use. Staff informed LPA that C1 would hallucinate during use. During one incident, staff informed LPA that they were following C1 when C AWOLd and appeared to be under the influence. C1 was trying to jump or pass through a fence and the staff tried to prevent C1 from doing so due to safety concerns. During this incident, C1's sweater got caught on the fence and tore. All clients informed LPA that staff have not handled clients in a rough manner. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator and a copy of this report, Confidential Names List, and appeal rights were provided to him.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Administrator Steven Anderson who assisted with the inspection. LPA investigated this complaint by reviewing incident reports, and by conducting confidential interviews with two clients, four staff, the Facility Manager, the Program Director, the Administrator, and the County Social Worker between 11/26/2024 and 4/29/2025. Despite making 11 attempts to speak with the client involved, LPA was unable to make contact with them. Confidential interviews with all facility personnel and all children informed LPA that staff have not made inappropriate comments towards clients, specifically calling a client a "pendejo." All clients informed LPA that staff do not speak inappriopriately to them. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 05/07/2025


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post licensing inspection at the facility and met with Reyes Bonilla, Program Director (PD), and Tegre Miles, Executive Director (ED), who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA and PD conducted a walk-through of the facility. LPA observed one deficiency: In the clients' bathroom, the water tap delivered water at 125.6 degrees, which is 5.6 degrees too high. LPA issued a Technical Violation advisory note for this. The water heater was turned down during this inspection. LPA completed the Physical Plant and Operations domains from the CARE Tool, and no other deficiencies were found. LPA was unable to complete this inspection on this date and will return on another date to do so. An exit interview was conducted with ED and PD and a copy of this report will be emailed to them with a read receipt, which will serve as their confirmation for receiving the document.

met_with: Reyes Bonilla


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post licensing inspection at the facility and met with Reyes Bonilla, Program Director (PD), and Steve Dogan, Administrator, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA completed the rest of the domains in the CARE Tool, and found: two out of five clients reviewed had not had a recent TB test completed and five out of ten staff reviewed did not meet the 40 hour annual training requirement. LPA issued two type B citations for these deficiencies. LPA also found that the majority of all clients' Needs and Services Plans reviewed had either no signatures, or one or two signatures; there was a lack of visitation information in the files; there was not a complete manual restraint log, however there were incident reports with attached descriptions; the length of time for each hold was not clear in the descriptions; two staff did not have complete proof of education or verified experience in their files; the facility was utilizing "fines" to be repaid back from a portion of the client's allowance to a fund for activities; and room sharing compatibility assessments were not completed. LPA issues Technical Violation advisory notes for these issues. An exit interview was conducted with Administrator and PD and a copy of this report will be emailed to them with a read receipt, which will serve as their confirmation for receiving the documents.

met_with: Reyes Bonilla & Steve Dogan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Connie Goldie and Alyssa Burgess, made an unannounced required two-year annual inspection and met with Administrator, Steve Dogan who assisted with the inspection. LPAs and Facility Manager Jamilliah Cabunoc conducted a walk through of the facility and observed: three client bedrooms, one media room, one kitchen, on garage, the living room area, staff office, and backyard. The facility was clean and in good repair, aside from one client bedroom which had a boarded window from a client behavioral incident. Plans to repair the window are in effect. Also in that bedroom, there was a hole in the wall from a punch or kick. This is also planned to be repaired. LPAs learned that the facility had a minor issue with mice, however the facility already has been dealing with it and the pest control company treated the issue by servicing it today and will return in two weeks to treat it again. The water temperature measured at 111 degrees Fahrenheit which is within the required temperature range of 105 - 120 degrees Fahrenheit. LPAs observed an adequate amount of perishable and non-perishable foods. All bedrooms had adequate bedding and supplies. All lights were working. All poisons and disinfectants were locked and inaccessible. Medication was locked and inaccessible. Medication records showed that the Centrally Stored Medication and Destruction Records were out of date. All other regulations and requirements were met for medications. LPAs interviewed three clients. LPAs reviewed two client files. LPAs found that the two client files reviewed were missing items involving the Needs and Services Plans and other details required to be in the file. Due to not being able to finish the client file review on this date, these issues will be addressed in the annual continuation inspection. LPAs observed the facility's Board of Directors minutes, which have completed adequately and as required. LPAs observed a current fire clearance. An exit interview was conducted with Administrator Steve Dogan and a copy of this report was emailed to him with a read receipt which will serve as the record of receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess returned to the facility's Administration Office located at Georgia Street, Vallejo, CA 94590 to complete the file review for the Annual Inspection started yesterday, 2/23/2022. LPA reviewed 3 client files and 6 staff files, including the Administrator and Facility Manager. Yesterday and today, LPA found in the client files, that all clients were missing their original Needs and Services Plans (NSPs), however, Administrator was able to retrieve them and show to LPA. Also missing were certain details in the NSPs, described in the attached citations and advisory notes. All clients were missing evidence of mental health services received. All clients had a health screening, TB test record, school information, placement agreements, required signed documents, JV220s and JV223s if necessary for psychotropic medications, consent forms, authorized representative information and cash/personal valuable records. All clients receive an allowance and can use the facility telephone. Based on the level system, the clients may also earn personal phone privileges. For the staff records reviewed, LPA found: all staff had the appropriate criminal record clearances and association to the facility. All staff met the education and experience requirements. All staff had their health screening and TB test. All but one staff had their required annual hours of training. The one staff who's annual training is not complete, was prevented from completing the requirement due to COVID-related travel issues. Additionally, three out of six staff reviewed had expired CPR/1st Aid training. On this date, the facility is being cited for the following violations of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 4 and the California Code of Regulations, Title 22, Division 6, Chapter 1, found during this annual inspection on 2/23/2022 and 2/24/2022: 1. 87095.61(f)(3) 2. 87095.61(f)(6) 3. 87065.1(d)(6)(A) 4. 87070(b)(14) 5. 87087(e) 6. 87068.2(b) 7. 80075(k)(7) Eight Technical Violation Advisory Notes (not citations), were issued for the other issues found during this inspection. Additionally, LPA issued two Technical Assistance Advisory Notes to the facility, which are not citations. An exit interview was conducted with Administrator and a copy of this report, all Advisory Notes, Confidential Names List, and appeal rights were emailed to him with a read receipt which will serve as the record of receipt.

Deficiencies:
87068.2(b): Needs and Services Plan

(b) The needs and services plan shall be trauma informed, culturally relevant, and age and developmentally appropriate and shall identify the child's needs in the following areas


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Facility Manager (FM) Tom Hermann who assisted LPA with the inspection. CCL received an incident report dated 1/27/2024 stating that client C1 (see confidential names list dated 2/7/2024) went to C1's room and was yelling because C1's door was removed, "as part of [C1's] suicidal watch." Earlier, C1 had barricaded in C1's room, so C1's door was removed. Staff intervened when C1 was yelling and C1 then did property destruction and threats. In another incident report dated 1/27/2024, it stated that earlier in the day, C1 was kicking a pool table, yelling at staff, and was attempting to harm themselves with a piece of plastic, which the staff was able to remove. LPA interviewed FM Tom Hermann and Administrator Steve Dogan. An emergency Child and Family Team Meeting was held on 2/5/2024 for C1. LPA reviewed CFT Notes and Action Plan and found they discussed placement. However, they did not discuss C1's safety in the facility, or any of the behavioral issues C1 has been displaying, C1's recent mental health struggles, or psychiatric hospitalizations. Program Director Reyes Bonilla will be requesting the next CFT be moved up sooner to be able to adequately address these issues. PD will inform LPA when this meeting is scheduled. After the meeting, the facility will send the notes to LPA. After investigation into these incidents LPA has found that while the intent behind removing the client's door was for safety, it is not clear that the steps to ensure it was not a personal rights violation were taken. LPA is issuing an advisory note, which is not a citation, to address this. Additionally, the incident report describing C1 attempting self-harm with a piece of plastic was limited in details to evaluate the danger of the plastic. LPA advised Administrator Steve Dogan to include more information in the incident report, such as where C1 was scratching with the plastic, what was the piece of plastic from, was it sharp, were there any marks on C1, etc. An exit interview was conducted with Program Director and a copy of this report was sent to Administrator Steve Dogan and PD.

met_with: Tom Hermann


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced Plan of Correction (POC) inspection at the facility and met with Facility Manager (FM) Tom Hermann who assisted LPA with the inspection. On 12/29/2023, LPA issued the citation: Type B - 87065(f): Personnel Requirements. The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present. This requirement was not met as evidenced by: Based on observation and statements, the facility failed to have at least one facility manager present at all times one or more clients are present. This is a potential Health, Safety, or Personal Rights risk to clients in care. POC: By POC due date of 1/29/2024. The facility will have trained all eligible staff as facility managers, with the topics specified in section 87065.1(b)(5)(A-M) and will submit the monthly staff schedule for February 2024 with facility managers noted on all shifts with children, and will submit the training records. Administrator Steve Dogan sent LPA the POC during LPA's inspection. No further action is necessary. LPA advised Administrator to ensure that POCs are sent timely, by the POC due date, to prevent the assessment of civil penalties for the failure to correct. An exit interview was conducted with PD and a copy of this report and clearance letter were sent to Administrator Steve Dogan and PD.

met_with: Tom Hermann & Reyes Bonilla


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Misty Valencia on 02/28/2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia met with Steve Dogan, Program Administrator and inspected the facility inside and out. LPA reviewed 1 of 3 child's records and 3 of 3 staff personnel files on site at the facility. LPA reviewed 1 of 3 child's psychotropic medications and medication records. LPA interviewed 3 of 3 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of 3 youth currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Steve Dogan, Program Administrator No deficiencies are being cited at this time. LPA conducted exit interview with Steve Dogan, Program Administrator

met_with: Steve Dogan, Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess and Health Program Specialist (HPS) Kayla Haith made an unannounced annual inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA, HPS, and Administrator conducted a walk through of the facility. LPA observed: three client bedrooms, one media/relaxation room, one dining room, kitchen, laundry area, garage, living room, three bathrooms, and staff office. Medications were inaccessible as required. Client Medication Administration Records were completed as required. There were separate Psychotropic Medication Administration Records for the psychotropic medications as required. There was an adequate amount of perishable and non-perishable food as required. The facility was clean. There was available foodware, in good condition. The hot water in the clients' bathroom measured at 143 degrees Fahrenheit, which is outside the required range of 105-120 degrees Fahrenheit. Clients had appropriate bedding and hygiene supplies. All clients had clothing as required. One client dresser was in disrepair with broken tracks/drawers. Outside in the backyard, there was an approximately 5 inch in diameter drain hole which was uncovered. There were no paper towels or soap in the media room bathroom. One seat out of eight passenger seats in the facility van had a broken/inoperable seat-belt buckle fastener. Disinfectants and knives were inaccessible to clients. LPA interviewed one staff. The staff was knowledgeable about the facility, however LPA recommends a refresher on mandated reporter requirements, and abuse reporting process. LPA and HPS went to the facility's administrative office located at Georgia Street, Vallejo, CA to conduct a file review and found: The board is meeting as required, and minutes are maintained. Board minutes were accessible to LPA. There are two clients placed currently, so the ratio is kept at 1:3, and staff are currently not conducting restraints unless another trained staff or Administrative staff come in to assist. LPA did observe the facility Pro-Act certified trainer's certification to be up-to-date. The facility plans to train additional staff on emergency interventions. All staff in the roster were fingerprint cleared and associated as required. All files were accessible to CCL as required. The client who is taking psychotropic medications had an accurate and updated JV223 as required. LPA was unable to complete the inspection and will return on another date to do so. An exit interview was conducted with Administrator and a copy of this report was provided to him.