summary: Facility Evaluation

raw_content:
Narrative:
On 08/13/24, Licensing Program Analyst (LPA) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Administrator, and informed Administrator on the purpose of the visit. LPA conducted one confidential interview related to an outside investigation. An exit interview was conducted, and a copy of this report was left with, Administrator whose signature on this form confirms receipt.

met_with: Ken Porter


state: CA

facility_name: FILBERT HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On 5-21-25 10:00AM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced an unannounced inspection at Filbert House and met with Administrator Ken Porter. The purpose of the visit was to follow up on IRFU 0001739FN. See LIC Confidential Names List dated 5-21-25. LPA conducted confidential interviews with staff. S1 stated the reason she did not give the house phone to C1 was because C1 was in a violent mood, reciting lyrics of shooting someone, wanted to call someone that was not approved, to come and assault S1. S1 stated it was a safety concern, and waited for the supervisor to arrive and handle the situation. S2 stated that C1 wanted to call his uncle, to come to the facility to assault staff. S2 stated that C1 had his own cell phone at the time of the incident and was purposely causing an unnecessary argument. S2 also stated staff safety was a concern. S2 stated that C1 shortly after apologized for his behavior. C1 went on AWOL 5-9-25 and has not returned, not available for comment. LPA conducted document research. C1's needs and service plans show a history of violent assaultive behavior. The incident report and shift notes both indicate that C1 wanted to call an unauthorized person to come and assault staff. At this time there are no deficiencies or further follow up needed.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Ken Porter, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 06-28-24 10:30AM, Licensing Program Analyst (LPA) George Karkazis made an unannounced inspection at Filbert House and met with Ken Porter, Administrator. The purpose of the visit was to follow up on an incident that occurred on 6-14-24, incident number 0000724-FN. Present during the inspection were two staff and two clients. LPA conducted document research in an incident report dated 6-14-24, sent by the Administrator, which indicates that staff hit the client several times and threw the client to the ground. LPA conducted confidential interviews, interviewees stated they witnessed staff physically assaulting a client, providing accurate details of the physical altercation. Staff immediately terminated. The facility is being cited for Title 22, Division 6, Chapter 1, Article Personal Rights 80072(a)(3). An exit interview was conducted, appeal rights provided, and a copy of this report was given to Ken Porter, Administrator.


facility_name: FIRST STEP

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
However, the facility addressed it and child was removed and moved to a different placement. Facility manager stated that staff coverage is typically one (1) overnight staff and 2 to 3 staff on duty for the mornings and afternoons. Staff #1 (S1) stated that they were unaware of any incidents where children acted inappropriately or where children got in trouble being on community passes. Additionally, Staff #2 (S2) stated that children in home get along and no issues have been observed or reported. Interviews conducted with children identify no issues in the home. Child #1 (C1) stated that all children got along and that he felt as though staff coverage was enough to tend to everyone's needs. Interviews conducted with child#4 (C4) stated that home is nice, and staff are attentive. LPA observed two (2) children who were non-verbal both clients were observed to be comfortable around staff, clean and being attended to. Interviews conducted with children and staff did not provide any specific information or details related to any one incident or occurrence. Documents reviewed did not depict any unusual or inappropriate behavior. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form and Appeal Rights were provided to the facility representative via electronic mail. There were no deficiencies cited during this tele-inspection.

Investigation Findings:
13On 5/25/ Licensing Program Analyst (LPA) Dawn Mahecha telephoned the First Step facility for the purpose of concluding the above complaint investigation. LPA spoke with Facility Manager Byron Butler regarding the findings to the above identified allegation. Investigation consisted of the following: On 12/23/ LPA conducted 10-day inspection to facility, interviewed Facility manager, one (1) child and requested documents (see LIC 811 confidential names, dated 12/23/20). Additionally, on 5/25/ LPA interviewed two (2) additional staff, one (1) child and observed two (2) non-verbal children. On 5/26/ LPA Mahecha reviewed information provided. Investigation revealed the following: It was alleged that a lack of supervision resulted in minors engaging in inappropriate behavior. Interviews conducted with facility manager stated that approximately 5 or 6 months ago prior to complaint investigation facility did have a child who would jump on the roof. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 05/25/2021

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

report_type: Complaint Investigation

met_with: Byron Butler, Facility manager

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Facility staff reported that the clients are aware of their rights and know they can only do so much to prevent them from awolling out of the facility; however, the staff attempts to re-direct them whenever they can. The confidential interviews did not corroborate the clients are being disruptive or causing the community any issues due to the lack of supervision. Interviewed parties were not familiar with the allegation of clients asking anyone for money or trying to take anyone belongings. Furthermore, facility staff denied having children on awol during the morning hours due to them being in school or doing schoolwork at that time. Therefore, based on the interviews and records reviewed the allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation. No other agency investigated the allegation. Exit interview was conducted and a copy of this report was emailed to the Facility staff for review and signature due to Covid-19 restriction. There were no citations.

Investigation Findings:
13On 6/02/2021, Licensing Program Analyst (LPA) Johanna Lofton conducted a telephonic follow-up inspection at First Step Group Home with the purpose of delivering findings regarding the above complaint allegation. LPA Lofton spoke to Lead Facility Manager Byron Butler and discussed the findings. During the investigation LPA Lofton made several attempts to reach the complainant on 11/19/20, 01/04/21 and 2/25/21. LPA Lofton left messages each day except 2/25/21 due to voicemail being full. LPA Lofton interviewed Staff #1 on 11/19/20, Staff #2 on 4/16/21, Staff #3 on 4/21/21 and Staff #4 on 4/23/21. LPA Lofton interviewed Client #1, Client #2 and Client #3 on 3/12/21. See LIC811- Confidential Names List dated 6/02/21. The allegation was denied by all interviewed parties. The facility staff denied the allegations that staff members are not supervising the clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Johanna Lofton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 06/02/2021

met_with: Byron Butler- Lead Facility Manager


raw_content:
Narrative:
Based on the interviews and records reviewed the allegation is found unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited.

Investigation Findings:
13On October 20,21 at 9:00AM Licensing Program Analysts (LPAs)Zeyda Loera and Pamela Silva conducted an unannonced inspection visit for the purpose of providing findings for the above complaint allegation. LPA met with Byron Butler, Lead Facility Manager. During the course of the investigation, LPA interviewed one clients on 10/20/21 (see Confidential Names Form LIC 811 dated ,10/20/21). LPA interviewed one facility staff on 09/21/21. LPA obtained and reviewed client's and staff documents. The facility staff denied the allegation indicating clients are not supervised at all time. Foster child 1(FC1) stated, staff is always supervising all children. FC1 stated, when clients go out in the community they always have a staff supervisiing at all times. FC1 deniied the allegation of not being supervised at all time. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Zeyda Loera LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 10/20/2021

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

met_with: Bryon Butler, Lead Facility Manager


raw_content:
Narrative:
The Department received a complaint regarding alleged sexual abuse on C1 by a FM. The FM denied the allegation. Statements obtained from confidential interviews conducted by SI Barragan, County Social Workers and Law Enforcement were consistent and revealed there were no witnesses who observed FM physically or sexually abuse clients placed at the facility. The investigations conducted by other agencies and departments revealed there was no evidence to corroborate the allegation. Based on statements obtained from interviews conducted and records reviewed the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence standard was not met. Exit interview conducted. No deficiencies were cited. A copy of this report and Confidential Names form LIC811 dated 4/21/22 were given to the above mentioned facility representative.

Investigation Findings:
An unannounced follow up complaint inspection was conducted on 4/21/22 at 8: AM by Licensing Program Analyst (LPA) Christopher Larios. During the inspection LPA Larios met with Facility Manager Kayla Johnson and delivered findings for the above mentioned complaint allegation. The complaint investigation was conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) State Investigator (SI) Maria Barragan. During the course of the investigation LPA Larios conducted a record review and obtained copies of the following documents: physician report, IEP, special incident reports, placement agreement, case notes, emergency identification information, needs and services plans, staff roster and contact information, facility sketch and client registry. SI Barragan interviewed one County Social Worker (CSW) on 1/10/22, one CSW on 1/27/22, four Clients (C2, C3,C4,C5) on 2/8/22, one CSW on 2/18/22, two Facility Managers (FM) on 2/22/22, two FM on 2/23/22 and one Administrator on 2/23/22, one FM on 3/10/22, one Detective on 3/10/22 and one FM on 3/17/22. SI Barragan attempted to interview Client (C1) on 2/18/22, but C1 is nonverbal and did not provide a statement. SI Barragan obtained a copy of a Law Enforcement report regarding the alleged incident on 2/18/22. CONTINUED UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 04/21/2022

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

met_with: Kayla Johnson


raw_content:
Narrative:
Confidential statements obtained during the investigation were unable to corroborate the allegations as there were no statements obtained to support the allegations. One of the residents is autistic and non-verbal. Facility staff denied the allegations. An unannounced tour of the facility revealed that the facility has ample food supply and hygiene products for the residents. Based on the information gathered, the allegations are unsubstantiated as the preponderance of evidence to prove the allegations was not met although the allegations may have happened or are valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On April 21, 2022 at 11: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up complaint inspection to deliver the findings of a complaint investigation concerning the allegations above. LPA Rarela met and discussed the findings with the facility representative named above. During the course of the investigation, LPA interviewed facility staff on 2/4/22, 2/7/22, 2/15/22, 4/15/22 and 4/21/22, and facility residents on 4/21/22 (see Confidential Names Form dated April 21, 2022). LPA also reviewed documents including placing agency service logs and reports, medical records, resident case plans and facility personnel records. It was alleged that the facility is not addressing changes in minor's health, and the facility is not ensuring minor's dental needs are being met. (CONTINUED) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 04/21/2022

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

met_with: Ariana Lopez, Lead Facility Manager


raw_content:
Narrative:
Investigation revealed the following: It was alleged that minor sustained an unexplained bruise while in care. Manager denied the allegation. Manager stated that children who were roommates had a physical altercation where one child bit a child and the other child reacted to being bit by hitting the child. A bruise was not initially observed by staff but child had teeth mark impressions on their arm and child later developed bruising. Manager stated incident was documented and children were moved to separate rooms. LPA was unable to interview children as one child is non-verbal and other child refused to speak with LPA. LPA reviewed interviews and observations conducted by LPA Joshua Rareula on March 23, 2022 and April 21, 2022. LPA Rarela made observations of child who was non- verbal and received confirmation from his teachers that child is unable to speak or respond to questioning. In additional interviews conducted with other children made by LPA Rarela children had similar statements in identifying issues with one child but that all children got along with staff and that they had not observed or been victim to any staff be physically abusive to children. Documents reviewed coincide with statements received in how child obtained bruising. Staff reported incident to agencies reporting incident and addressed the issue by transitioning children to different rooms and intervening when necessary. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On 05/6/ Licensing Program Analyst (LPA) Dawn Mahecha made an announced visit to the First Step facility to deliver the findings to the above identified complaint investigation. LPA spoke with Administrator Crystal Carrillo and informed manager of investigative findings. Investigation consisted of the following: On 1/21/ LPA Karen McGee conducted 10-day inspection to facility (see LIC 811 confidential names, dated January 21, 2022). Between 4/29/22 and 4/30/ LPA interviewed one (1) child and reviewed previous interviews and observations made by LPA Joshua Rarela. Additionally, LPA interviewed additional staff. LPA attempted to contact county social worker (CSW) and therapist. On 4/30/ LPA reviewed documents received and information provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 05/06/2022

met_with: Crystal Carrillo, Facility manager


raw_content:
Narrative:
The LPA observed that the client was placed at the facility on March 5, 2020 and removed on September 30, 2021. The LPA observed an Appraisal/Needs and Services Plan dated October 1, 2020. The LPA observed that the County Placement Worker signed the document on January 20, 2021. The LPA observed a Quarterly Report dated September 17, 2021. The investigation revealed that the initial County Social Worker was no longer assigned the case. It is determined that the facility provided an Appraisal/Needs and Services Plan as required by the Plan of Operation. It is noted that the Appraisal/Needs and Services Plan is not within the 90 day plan, but consideration is given due to the Covid Pandemic. The LPA cannot corroborate that the facility did not provide paperwork. The investigation revealed that the facility was aware for two-to-three months of the plan to transfer Ref. #1 to an adult residential facility. It revealed that the facility had less than less than 24 hours to pack Ref. #1's belongings for the transfer once they received the call that a placement was open for Ref. #1. The LPA was provided inconsistent statements as to whether Ref. #1's belongings were provided in either a box or bags. It revealed that the witness stated a box, but no details were provided as to whether it was a moving box. The investigation revealed that the witness was concerned more with the lack of contents in the box as opposed to the container the belongings were transported in. The LPA cannot corroborate the allegation that Ref. #1's belongings were not provided. The LPA cannot corroborate evidence to determine if there was a Personal Rights violation based upon the type of container Ref. #1's belongings were transported. The LPA reviewed the Medical Treatment Record dated June 23, 2020 signed by the physician; and the Health and Education Passport dated February 16, 2021. The LPA cannot corroborate the allegation that the client was not taken to their medical appointment. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided to the facility representative.

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

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

met_with: Crystal Carrillo


raw_content:
Narrative:
Ref. #1 revealed that the proper procedures were followed for them to foster Ref. #2 and Ref. #2 was provided home passes in order to visit Ref. #1's home and meet Ref. #1's maternal parent and sister, who lived in the home. Ref. #2 denied the allegation, stating that Ref. #1 served as a role model and took care of Ref. #2. The investigation revealed that there were no allegations of sexual inappropriateness made against Ref. #1. It revealed that the facility conducted a meeting with Ref. #1 regarding favoritism with the clients. The CSW expressed concerns about the rumors started by another client at the facility. The LPA cannot corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that an alleged violation occurred, therefore the allegation is unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided to the facility representative.

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

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

met_with: Ronnie Mackey


raw_content:
Narrative:
The LFM disclosed after Ref. #1 was asked if Ref. #1 was okay to attend school, Ref. #1 informed staff that Ref. #1 was okay to attend school. The LPA observed an SIR from the facility to MPCRP reporting the incident and a Law Enforcement Contact Report (LIC 624-LE) dated February 4 reporting that law enforcement came to the facility to conduct a wellness check on Ref. #1. The investigation revealed inconsistent statements regarding the request for communication from the facility. The investigation revealed statements that the facility was telephoned several times and messages were left regarding Ref. #1 being taken to the hospital. The statements alleged that Ref. #1's biological mother was contacted to reach the facility. The LFM disclosed that they received the telephone calls while in a meeting. The LFM disclosed that no message was left on the voicemail. It revealed that the LFM returned the call, but did not know who was calling. The LFM revealed that they received a telephone call at around 10:45 or 11 a.m. that Ref. #1 was being transported to the hospital by ambulance. The investigation revealed that the LFM met the client at the hospital. An interview with Ref. #1 revealed that the LFM had told Ref. #1 the morning of February 3 that they would take Ref. #1 to the hospital, but Ref. #1 did not tell the LFM that Ref. #1 wanted to go. The LPA was unable to corroborate the allegations There was no preponderance of the evidence to substantiate the allegation. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding this allegations. A copy of this complaint was provided to the facility representative.

Investigation Findings:
On May 11, 2023 at 3:10 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a complaint investigation. The LPA met with Facility Manager (FM), Crystal Carrillo On February 3, 2023, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: Lead Facility Manager (LFM), Byron Butler at the facility on February 7, 2023; client (see Confidential Names, LIC Ref. #1 dated May 11, 2023) at school on April 14, 2023. The LPA was unable to speak with the County Social Worker after leaving messages. The LPA reviewed Special Incident Reports and Ref. #1's Needs and Services Plan. The investigation revealed that on the January 28, Ref. #1 sustained an injury in his private area after horseplaying with another client at the facility when the other client accidently kicked Ref. #1. The LPA was provided inconsistent information as to when the injury was reported to the facility staff. One statement alleged that it was reported to staff on the same date that it was sustained. The LFM disclosed the incident was not reported until February 3, 2023 after Ref. #1 was observed limping at the facility before going to school. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 05/11/2023

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


raw_content:
Narrative:
Based on the information obtained during the investigation, it cannot be determined whether the above allegations occurred. Based upon interviews, the complaint findings are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations occurred. No deficiencies were cited. Exit interview was conducted, and a copy of this report was emailed to the above-named facility staff.

Investigation Findings:
On August 13, 2023, Licensing Program Analyst (LPA) Johanna Lofton, conducted a follow up inspection visit to First Step STRTP with the purpose of delivering findings for the above complaint allegation. LPA Lofton met with Kayla Johnson, Direct Care Staff, and discussed the findings. During the complaint investigation, LPA Lofton conducted confidential interviews with facility staff, facility clients, and social workers. During the investigation, LPA Lofton conducted confidential interviews. During the conducted interviews, facility staff denied the allegation. Furthermore, facility staff reported that facility clients were not awoling and reported the teens observed vandalizing the park might have been from another facility located in the vicinity. Interviewed facility clients denied vandalizing the park or being at the park during Christmas. Complainant did not provide evidence that the teenagers observed were from First Step STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Lofton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 08/13/2023

met_with: Kayla Johnson - Direct Care Staff


raw_content:
Narrative:
The LPA observed Ref. #1's allowance log. The LPA observed an accumulated balance and no withdrawal of funds from Ref. #1's allowance from August 2024 thru mid-October 2024. The LPA observed a withdrawal of funds at a mid-point in October 2024. The LPA observed another accumulated balance from mid-October thru November 2024. The LPA observed Ref. #1's initials by each entry starting in August and ending in November on the allowance log. There was a statement made that staff would not allow Ref. #1 to utilize a bathroom that was located in the master bedroom. The investigation revealed that Ref. #1 was not assigned to sleep in the master bedroom, but slept in the middle bedroom that did not have a bathroom. Two other clients were assigned to the master bedroom. It revealed that Ref. #1 was allowed access to the bathroom in the hallway. The LPA was unable to corroborate the allegations. There was no preponderance of the evidence to substantiate the allegations. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided to the facility representative.

Investigation Findings:
13On January 24, 2025 at 11:40 a.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a complaint investigation. The LPA met with Lead Facility Manager, Crystal Carillo. On October 9, 2024, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: the Administrator via telephone and the Lead Facility Manager at the facility on January 23, 2025. The LPA reviewed the Client's Ref. #1's Needs & Services Plan and Allowance Log. After checking, the LPA did not observe any incident reports involving Ref. #1. There were statements made that the facility would not give the client their allowance in a timely manner. The investigation revealed that the facility staff dispensed the allowance on the weekends, and asked clients if they wanted to spend or save their allowance. It revealed that Ref. #1 was 18 years old and would leave the facility on the weekends, not being present when the allowance was dispensed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 01/24/2025

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

met_with: Crystal Carillo


raw_content:
Narrative:
On 2/27/25, the Department received a complaint alleging: Staff kicked client. Based on the information gathered during confidential interviews, all relevant parties denied the allegation. Confidential interviews conducted during the investigation were unable to corroborate the allegation as there were no witnesses nor statements obtained to support the allegation. Based on the information gathered, the allegation is unsubstantiated as the preponderance of evidence to prove the allegation was not met although the allegations may have happened or are valid. A copy of this report, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
On April 17,2025, Licensing Program Analysts (LPA) Angelina Garibaldo made an unannounced visit to the STRTP for the purpose of delivering findings to the above complaint investigation. LPA met with representative and discussed the following findings. Investigation consisted of the following: On 3/4/ LPA conduced 10-day at facility, reviewed files of (2) clients, requested copies of the current LIC Personnel Report, Client Roster, Client's Needs and Services Plans for C1 and C2, and school information for all client in care, LPA Garibaldo conducted interviews with one staff (S1) and three clients C1, C2, C3. On 3/24/ LPA Garibaldo interviewed Reporting Party (RP) and County Social Worker (CSW). On 3/31/ LPA Garibaldo interviewed one Client (C4) and three staff (S2, S3, S4). (see Confidential Names forms LIC811 dated, April 17, 2025). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Angelina Garibaldo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 04/17/2025

met_with: Crystal Carrillo - Lead Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/08/21 at 9: AM, Licensing Program Analysts (LPA) Zeyda Loera and Pamela Silva conducted an Annual Required Inspection to the Short Term Residential Therapeutic Program (STRTP). LPAs met with Administrator Gina Sodaro and Lead Facility Manager Bryon Butler. This STRTP is licensed to serve up to six (6) male ambulatory clients ages 7-17 and is also licensed to provide services to Non-Minor Dependents (NMD). There are six (6) clients currently in placement. The LPAs requested the following: Personal Report LIC 500, Client Roster, Board of Directors Meeting Minutes, Clients and Staff files. At 9: AM, LPAs conducted a walkthrough of the entire facility. Physical Plant The STRTP license, Mental Health Certification, National Accreditation and the Emergency Disaster Plan are posted in the facility. Passageways are unobstructed. Disinfectants, cleaning solutions, other chemicals, sharps and knives are kept locked in the hallway closet. Medications are centrally stored in a locked closet. The temperature inside the facility is maintained between 68 and 85 degrees (F). Hot water temperature was measured at 118 degrees (F). Carbon monoxide and smoke detectors were tested and observed to be operational. The fire extinguishers are fully charged. Facility has a working telephone. First Aid kit is complete. All confidential files are in a locked cabinet inside the staff office. All sinks, showers and toilets are in working order. No more than 2 clients share a bedroom. All beds are in good condition, equipped with good springs, clean mattresses and pillows. There were adequate supply of beddings and linens. Facility provides age-appropriate clothing items and hygiene products. The facility has cameras installed in the common areas of the facility. There are no firearms and ammunition in the facility. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The Board of Directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed and maintained and implemented written complaint procedures. Client Records LPAs reviewed six (6) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, removal/discipline/complaint procedures, medical assessment, safeguards for cash resources, personal property and valuables, education records, personal rights forms and medication administration records. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. The administrator meets the required qualifications and/or experience. Documentation of the required education and experience requirements are maintained in the personnel file. Facility Managers meet requirements. Annual training records and certificates are on staff files. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services, transition support services, educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts drills at least quarterly for each shift. The drills are documented and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, needs and services plans for each client, medication records, and contact information for each client's responsible party and physician. LPAs interviewed two (2) staff members. LPAs were unable to interview clients due to no client was present in the facility at the time of inspection At the conclusion of the inspection, LPAs discussed the findings with the facility Administrator. LPAs agreed to work with the facility administrator to collaborate with guidance to get the facility in compliance with ILS and Title 22 regulations. The administrator was provided with information on where to locate the Provider Information Notices (PINs), guidance to the new CARE Tools inspection process and Guardian. There was no deficiency cited during today's inspection. An exit interview was conducted and a signed copy of this report and LIC811 were provided to the Administrator..

visit_type: Annual

met_with: Gino Sodaro, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 05/19/23, Licensing Program Analyst (LPA) Joe Martinez made an unannounced case management inspection at the facility mentioned above. LPA met with facility manager (FM) On 05/10/23, the Department received an Incident Report (IR) communicating an upset minor, who had been reprimanded at school for using his phone during class hours. The minor reacted violently to staff, when he arrived at the facility. Behavior included cursing, hitting and kicking another resident with a blender and a broom, and damaging the facility's van by slashing its tire with a pocketknife. Staff attempted to de-escalate the situation verbally, however, the client left the facility before law enforcement arrived. The police later apprehended the client at 4: PM in the community and transferred him to a juvenile hall. During the time of inspection,LPA interviewed FM in order to gather additional details related to the incident.More information is needed to conclude the investigation related to the above incident. There are no deficiencies to be cited at this time. An exit interview was conducted and due to technical difficulties with the LPA's printer, a copy of this report was emailed to FM.

met_with: Byron Butler - Facilty Manger


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Timika Martin, Juliet Robles and Angelina Garibaldo on 08/24/23 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Byron Butler, Facility Manager and inspected the facility inside and out. LPAs reviewed one (1) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed one (1) of children's psychotropic medications and medication records. LPAs interviewed one (1) staff on site to discuss the facility's policies and procedures of operation. There were no clients available to conduct an interview. No deficiencies are being cited at this time. LPA conducted exit interview with Byron Butler, Facility Manager and provided a copy of this licensing report.

met_with: Byron Butler, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 11/2/23, Licensing Program Analysts (LPA) Joe Martinez and Juliet Robles conducted an Annual/Random Inspection of the Short Term Residential Therapeutic Program (STRTP). LPAs Martinez and Robles met with Lead Facility Manager Byron Butler. The STRTP is licensed to serve up to six (6) male ambulatory clients ages 7-17 and is also licensed to provide services to Non-Minor Dependents (NMD). There are five (5) clients currently in placement. At 11: AM, LPA Martinez conducted a walk through of the facility. Physical Plant: · The Short-Term Residential Therapeutic Program (STRTP) license, Mental Health Certification, National Accreditation, and Emergency Disaster Plan are posted in the facility. · Passageways are unobstructed. · Disinfectants, cleaning solutions, other chemicals, sharps, and knives are locked in the hallway closet. · Medications are centrally stored in a locked closet. · The facility maintains a temperature range of 68 to 85 degrees (F). · Hot water temperature measures at 115 degrees (F). · Carbon monoxide and smoke detectors are operational. · Fire extinguishers are fully charged. A working telephone is available. · The First Aid kit is complete. · All confidential files are in a locked cabinet inside the staff office. · All sinks, showers, and toilets are functional. · No more than two clients share a bedroom. · All beds have good springs, clean mattresses, and pillows. · There is an adequate supply of bedding and linens. · The facility provides age-appropriate clothing items and hygiene products. · Cameras are installed in the common areas of the facility. · There are no firearms or ammunition in the facility. · Overall, the facility is clean, safe, sanitary, and in good repair Operations: • The facility maintains a register of clients. • The Board of Directors regularly reviews and discusses STRTP's operation. • The facility administrator and manager communicate with emergency personnel. • The facility has written complaint procedures in place. Client Records: • Five (5) client records were reviewed during the inspection. • All client records are available to the licensing agency upon demand. • Client records contain required information,examples included consent forms, court orders, needs and services plan, removal/discipline/complaint procedures, medical assessment, safeguards for cash resources, personal property and valuables, education records, personal rights forms.. Staff Records: • LPAs reviewed five (5) staff records. • All staff have cleared criminal records reviews and fingerprinting by DOJ, FBI, and CACI. • The Administrator meets the required qualifications and experience. • Documentation of education and experience requirements is maintained in personnel files. • Facility Managers meet requirements. Core/Therapeutic Services: • The facility provides core services and supports to children and non-minor dependents, including: • Medi-Cal specialty mental health services. • Educational and physical, behavioral, and mental health supports. • Activities to support children and non-minor dependents. • Services to achieve permanency. Disaster Preparedness Plan: • The facility maintains a current written disaster and mass casualty action plan. • Drills are conducted and documentation is maintained for at least a year. • An emergency and disaster plan, a register of clients, needs, and services plans for each client, medication records, and contact information for each client's responsible party and physician are maintained. Interviews: • Two (2) staff interviews • Two (2) client interviewed during the inspection. Findings: • No deficiencies were cited during the inspection. • An exit interview is conducted, and a signed copy of the LIC809 are provided to the Facility Manager.

met_with: Byron Butler


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles on 10/17/24 at 12: PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Byron Butler, Facility Manager, and inspected the facility inside and out. LPAs reviewed zero (0) of child's records and three (3) of staff personnel files on site at the facility. One child taking psychotropic medication is over the age of 18. LPAs reviewed zero (0) of child's psychotropic medications and medication records. LPAs interviewed one (1) of staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed zero (0) child currently prescribed psychotropic medication. No deficiencies are being cited at this time. LPAs conducted exit interview and provided a copy of this report to the Facility Manager, Byron Butler.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/2/24, Licensing Program Analysts (LPA) Caitlin Chambers and Joe Martinez conducted an Annual/Random Inspection of the Short Term Residential Therapeutic Program (STRTP). LPAs Chambers and Martinez met with Lead Facility Manager Byron Butler. The STRTP is licensed to serve up to six (6) male ambulatory clients ages 6-19 years of age and is also licensed to provide services to Non-Minor Dependents (NMD). There are five (6) clients currently in placement. At 10: AM, LPA Chambers and LPA Martinez conducted a walk through of the facility. Physical Plant: · The Short-Term Residential Therapeutic Program (STRTP) license, Mental Health Certification, National Accreditation, and Emergency Disaster Plan are posted in the facility. · Passageways are unobstructed. · Disinfectants, cleaning solutions, other chemicals, sharps, and knives are locked in the hallway closet. · Medications are centrally stored in a locked closet. · The facility maintains a temperature range of 68 to 85 degrees (F). · Hot water temperature measures at 115 degrees (F). · Carbon monoxide and smoke detectors are operational. · Fire extinguishers are fully charged There are three bedrooms and two bathrooms. All bedrooms are being utilized. Further inspection needs to be done at a later date. There are two Clients per room. The backyard is free of obstruction. The number of Client and Staff being interviewed on this day is three. Final inspection will be completed at another date. The purpose of this visit was to do a continuation of an annual inspection on the date of January, 07, 2025. Licensing Program Analyst Caitlin Chambers and Licensing Program Analyst Joe Martinez met with Crystal Carrillo , the faciltiy manager. Medication check: Licensing Program Analyst Chambers (LPA) reviewed one psychotropic medication was checked with a medication log filled out appropriately, for C3 (See Client Confidential names). Client Files/Staff Files: Three Client Files and Two Staff files were reviewed. LPA Chambers reviewed one client file and one client file , while Licensing Program Analyst (LPA) Martinez reviewed three client records and three staff records. Client records reviewed included, but not limited to, consent forms, court orders, appraisal/needs, and services plan (if applicable), removal/discipline/complaint procedures; medical assessments; safeguards for cash resources, personal property and valuables; education; personal rights forms. Disaster Preparedness Plan: LPA Chambers observed a current, written disaster plan. LPA Chambers witnessed the disaster drill plans are completed at least every month for each shift. The documentation is maintained in the files. LPA Chambers found an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services: LPA Chambers analyzed the core services and supports to children as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate. A copy of this report was given to the facility manager. Appeal rights rights were review.

met_with: Crystal


summary: Facility Evaluation

raw_content:
Narrative:
On January 24, 2025 at 11:40 a.m., Licensing Program Analyst (LPA), Karen McGee, conducted a Case Management for the purpose of reviewing an issue regarding the bathroom in the master bedroom. The LPA met with Lead Facility Manager, Crystal Carillo. On January 23, 2025, at LPA McGee's request, Lead Facility Manager (LFM), Crystal Carillo provided the LPA a tour of the bathrooms and bedrooms at the facility. The LPA observed three bedrooms. The LFM informed the LPA that they have six clients, two clients in each bedroom. The LPA observed that the first bedroom (master) has a bathroom. The bathroom had a sign marked staff bathroom. he LFM informed the LPA that they were given permission by their Monitoring LPA to use that bathroom for staff. LPA McGee confirmed that the facility was given information in error and informed the LFM and Administrator Gina Sordano that the facility was in violation of Interim Licensing Standard (ILS): Buildings and Grounds.87087(b)(5). No bedroom shall be used as a public or general passageway to another room, bath or toilet. The LPA requested that the facility personnel remove the sign, and informed them that no facility staff or clients not assigned to sleep in the master bedroom are allowed to utilize the master bedroom as a walkway to the bathroom located in that bedroom. The facility was given an Advisory Note for a Technical Violation in lieu of a citation since they were provided information in error. The LPA directed the facility personnel to their Monitoring LPA's Manager for further consultation regarding that bathroom. A copy of this report was emailed to the facility's authorized representative.


summary: Facility Evaluation

raw_content:
Narrative:
On February 14th, at 10:00am Licensing Program Analyst, Caitlin Chambers, made a visit to First Step for the purpose of writing the report as a revision page. The following report was conducted on January 7th, 2025 as a continuum report by Licensing Program Analyst Caitlin Chambers and Licensing Program Analyst Joe Martinez. While generating a continuum page on January 7th, 2025, and 809C was generated for the annual report from November 7th, 2024. The purpose of this visit was to do a continuation of an annual inspection on the date of January, 07, 2025. Licensing Program Analyst Caitlin Chambers and Licensing Program Analyst Joe Martinez met with Lead Facility Manager (LFM), Crystal Carrillo , the facility manager. Licensing Program Analyst Chambers (LPA) reviewed one psychotropic medication was checked with a medication log filled out appropriately, for C3 (See Client Confidential names).on 01.07.25. This client was the only client who took a psychotropic medication. No other clients were prescribed psychotropic medication. LPA Chambers reviewed one client file and one staff file, and all medical history files (all medical files for all clients were in one binder) and LPA Martinez, reviewed three client records and three staff records. Client records reviewed included, but not limited to, consent forms, court orders, needs, and services plan, activity sheets by the month, removal/discipline/complaint procedures,; safeguards for cash resources, personal property and valuables; education; personal rights forms. LPA Chambers observed a current, written disaster plan, disaster drill plans there were completed each month, an emergency and disaster plan, register of clients, medication records, and contact information for each client's responsible party and physician. All personnel have submitted fingerprints. All personnel subject to a criminal record review have obtained a California clearance by the Department or requested a transfer of criminal record clearance prior to working. The agency social workers have master's degrees from accredited graduate schools of social work or meet additional requirements. Staff members are qualified for their responsibilities. Personnel records are maintained on the licensee, supervisors and employees which contain health screening, tuberculosis test documents, valid CPR certificates and child abuse trainings. A copy of this report was given to the facility manager with an LIC 811 dated January 7th,2025. No deficiency were found at this time. No citation was given during this visit. An exit interview was conducted. A printed report was given to the LFM Carillo.


summary: Facility Evaluation

raw_content:
Narrative:
On February 14th, 2025 at 11:15am Licensing Program Analyst (LPA, Caitlin Chambers, conducted a case management at First Step. The purpose of the visit is to review an issue regarding the bathroom in the master bedroom. The LPA met with Lead Facility Manage (LFM), Crystal Carillo. LPA Chambers toured the facility with LFM Carillo of the bathrooms and bedrooms at the facility. The LPA observed three bedrooms. The census of the facility is six clients, two clients per bedroom. The two clients that occupy the master bedrooms as their rooms are (C5 and C6 ) The LPA observed that the first bedroom (master) has a bathroom, creating a passageway to anyone who is not a client occupying the two beds in the master bedroom. LFM Carillo stated that the facility was using the master bathroom as the staff bathroom only which had two clients utilizing the master bedroom as their bedroom, but not the bathroom. The LFM allso stated they only use the bathroom when the children are at school, as a staff bathroom prior to LPA Chambers visiting the facility on November 7th, 2024. A technical violation was issued by LPA Karen McGee on February 24th, 2025, based on the following: Interim Licensing Standard (ILS): Buildings and Grounds.87087(b)(5). No bedroom shall be used as a public or general passageway to another room, bath, or toilet. LPA Chambers advised LFM, Carillo that no one should be allowed to use the master bathroom except for the two clients that occupy the bedroom. An exit interview was conducted. A work order will be given one month from now, March 14, 2025. A printed report was given to the LFM Carillo.


summary: Facility Evaluation

raw_content:
Narrative:
On September 25, 2025, at 10: AM Licensing Program Analyst (LPA) Timika Martin conducted an unannounced follow up case management inspection at the facility mentioned above and met with Crystal Carrillo, Facility Manager regarding a Special Incident Report (SIR) dated August 19, 2025, that was submitted to Community Care Licensing (CCL) on August 20, 2025. The SIR indicated that C1 had cut himself on the wrist while staff was in the bathroom. The SIR indicated that staff offered to clean up the blood from the cut but C1 became hostile and stated that he wanted to kill himself, he hated his life, and he wanted to end it. Based on a record review, staff offered medical attention and contacted the paramedics. C1 was taken to the hospital and was put on a suicidal watch hold. During the inspection, LPA Martin conducted a tour of the facility, reviewed and requested copies of C1's needs and services plan, school information, current Special Incident Reports (SIRs), C1's safety plan and medical records and CFT meeting notes. LPA requested staff contact information, staff shift schedule and staff training. LPA conducted one interview. An exit interview was conducted and a copy of this report and the LIC 811 were discussed and left with Crystal Carrillo, Facility Manager whose signature on this form confirms receipt of these documents. Additional follow up is needed .

met_with: Crystal Carrillo, Facility Manager


raw_content:
Narrative:
Confidential interviews were completed on 06/13/ S1, C2, 10/02/25-S2, 10/20/25-S3. LPA Martinez made three documented attempts to contact Reference 1 and Reference 2 on 7/28, 10/9, and 10/20 to obtain their statements regarding the allegation. As a result, no first-hand information or case-related details could be gathered from R1 and R2. (Reference Confidential Names Form LIC 811, dated November 07, 2025) The Department investigated a report that a youth (C1) was not allowed to return to a Short-Term Residential Therapeutic Program (STRTP) after leaving the facility without permission. Facility staff were interviewed and denied the allegation. Staff stated that the youth was not refused reentry and that the program remained willing to accept the youth back if released from law enforcement custody. Multiple attempts were made to contact the principal youth and involved stakeholders to complete an interview. The interview was not completed, and a statement from the youth (C1) was not included in this investigation. The record review included facility, stakeholder files, and relevant correspondence. Stakeholder reports showed that the youth described the facility positively and did not report being denied reentry or mistreated. No documentation or interview indicated that the youth was wrongfully evicted. Facility documentation reviewed, stating the facility's willingness to readmit the youth upon release from law enforcement custody. Documentation between the facility and stakeholders demonstrated continued willingness to provide care for the youth. Based on the confidential interviews and records reviewed, the complaint is unsubstantiated. An unsubstantiated determination means the allegation lacks a preponderance of the evidence to prove that the violation occurred. There are no deficiencies to be cited at this time. LPA Martinez conducted an exit interview and provided a signed LIC 9099 to the facility representative.

Investigation Findings:
13On 11/07/25, Licensing Program Analyst (LPA) Joe Martinez conducted a follow-up complaint inspection at the Short Term Residential Therapeutic Program (STRTP). LPA Martinez met with the facility representative named above. The inspection aims to deliver the finding for the above allegation(s). On 06/12/25, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): Wrongful Eviction LPA Martinez investigated the above allegation. The investigation included a review of records and confidential interviews, but it was not limited to these. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Joe Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 11/07/2025

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

met_with: Crystal Carrllo


raw_content:
Narrative:
LPA also reviewed Department databases and reports from other agencies. On September 23, 2025, the Department received a complaint report alleging that about 2-3 weeks earlier, staff were present and did not take action when one client attacked another client at the facility, resulting in injuries to one of the participants. It was also alleged that staff did not prevent a client from making sexualized and/or violent comments to a client. Lastly, it was alleged that a client did not feel safe in the home any longer. Staff denied the allegations that staff members allow clients to attack one another. Interviews with staff revealed that staff intervene verbally, trying to redirect clients, and that if that does not work, the they separate the clients into one of two living rooms in the home or take one on a drive while they cool down. Staff stated that when clients are bad mouthing each other, they also turn to redirection before moving to separate clients if redirection does not work. Interviews were consistent in that staff provide a safe environment for the minors, stating that they do what they can to stop any issues from boiling over. 3 of four professional contacts disclosed no concerns with the STRTP. LPA was unable to make contact with one professional contact. Confidential interviews conducted by LPA revealed contradicting statements regarding the allegations. Statements were made that clients will provoke one another when staff is not in their immediate presence, so things are happening by the time staff knows about it, with staff intervening at that point. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are determined to be Unsubstantiated. No deficiencies were cited at this time. Exit interview conducted. A signed copy of this report, LIC9099-C, and LIC811 were provided to Crystal Carrillo, Lead Facility Manager. Appeal rights provided.

Investigation Findings:
13On Thursday December 4, 2025 at 11:45 a.m., Licensing Program Analyst (LPA) John Bonilla conducted an unannounced follow-up complaint inspection at First Step, a Short-Term Residential Therapeutic Program (STRTP), for the purpose of delivering findings concerning the above allegations. LPA met with Crystal Carrillo, Lead Facility Manager. During the course of this inspection LPA reviewed the STRTP's complaint history, and attempted interviews by phone with 2 adults on September 26, 2025. On September 25, 2025, LPA Timika Martin conducted the initial 10-day inspection at the facility on behalf of LPA Bonilla. On October 7, 2025, LPA interviewed 1 client. On October 9, 2025, LPA interviewed 3 clients. On November 20, 2025, LPA interviewed 3 professional contacts. On December 3, 2025, LPA interviewed 6 staff. LPA reviewed documents provided by the STRTP including but not limited to LIC9020 register of clients, LIC Facility Personnel list, Needs and Services Plan (NSP) for clients 1-4 (C1-C4)(See LIC Confidential Names list dated 09/25/25), STRTP training logs, relevant Special Incident Reports (SIRs). (Continued...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: John Bonilla LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: FIRST STEPFACILITY NUMBER: VISIT DATE: 12/04/2025

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

met_with: Crystal Carrillo, Lead Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jenny Mundo and Pamela Silva on August 17, 2022 at 9: AM. During the inspection, LPAs met with Gina Sodaro, Administrator. LPAs and the Administrator inspected the facility inside and out. LPAs reviewed four (4) child's records on site at the facility at 9: AM. Two out of four clients' initial Needs and Services Plans were not developed within 30 days of placement and also lacked the authorized representatives signatures. LPAs reviewed three (3) staff personnel files on site at the facility at 11: AM. LPAs reviewed four (4) child's psychotropic medications and medication records at 10: AM. LPAs interviewed three (3) staff on site at 11:35 am. LPAs were unable to interview clients due to not being at the facility at the time of the inspection. LPAs conducted exit interview with Gina Sodaro, Administrator at 12: PM. LPAs provided the Summary Report to the facility representative upon completion. Two (2) citations were issued during today's inspection.

met_with: Gina Sodaro, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Timika Martin and Pamela Silva on 4/15/26 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Administrator, Shakila Mackey and inspected the facility inside and out. LPAs reviewed 1 child record and 3 of staff personnel files on site at the facility. LPAs reviewed 1 child psychotropic medications and medication records. LPA was unable to interview client due to cognitive/developmental barriers. LPA interviewed 2 of staff on site to discuss the facility's policies and procedures of operation. No deficiencies are being cited at this time. A Technical Advisory was issued (see LIC 9102). LPAs conducted exit interview and provided a copy of this licensing report to Administrator, Shakila Mackey.

met_with: Shakila Mackey, Administrator


facility_name: FIRST STEP TREATMENT HOME

raw_content:
Narrative:
Confidential interviews stated C1 was at the facility for about ten days, C1 refused to follow facility rules and C1 was an AWOL risk. Confidential interviews stated all clients are treated with respect, the food menu and the activity calendar are followed however, other information provided alleged the incidents occurred. Based on confidential interviews, the allegations that facility staff argue with Client #1 (C1), facility staff do not provide enough for C1 to eat and facility staff do not provide activities for C1 while in care may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was emailed to Facility Administrator Deanna Mellos.

Investigation Findings:
13On August 05, 2022, at 12:00 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Facility Administrator Deanna Mellos of First Step Treatment Home to discuss the investigative findings for the allegations noted above. On September 09, 2021, at 12:15 p.m., Licensing Program Analyst (LPA) Marisol Lopez met with Facility Manager Antonio Tucker to conduct an unannounced initial complaint investigation. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with four staff (S1-S4), four clients (C1-C4), and reviewed incident reports. On September 01, 2021, the Department received allegations that facility staff argue with Client #1 (C1), facility staff do not provide enough for C1 to eat and facility staff do not provide activities for C1. Confidential interviews contradicted the information stating that staff do not argue with any clients; food and snacks are always available to clients; and clients are provided with daily activities, weekend outings and follow a monthly activity calendar. (see continuation form LIC9099-Cdated 08/05/2022) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 08/05/2022

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

met_with: Deanna Mellos


raw_content:
Narrative:
Confidential interviews stated it was unknown what provoked C1 to contact law enforcement, however when law enforcement arrived, C1 was put on a 5150 due to threats of self-harm. Confidential interviews denied C1 was bullied by other minors or staff however, C1 was unable to be interviewed for further information. Based on confidential interviews, although the allegations that staff is allowing C1 to be bullied by other minor(s) in care, may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Facility Manager Antonio Tucker.

Investigation Findings:
13On 12/02/2022, at 1:25 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Facility Manager Antonio Tucker, of First Step Treatment Home to discuss the investigative findings for the allegation noted above. On 03/01/2022 at 2:00PM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced complaint investigation at the above facility and met with Facility Manager (FM) Antonio Tucker. LPA conducted a safety inspection, and no deficiencies were observed at that time. The investigation consisted of confidential interviews with one facility administrator, three facility staff, one service worker and review of incident reports. LPA attempted to interview client #1 (C1) however C1 was unable to be interviewed. On 02/24/2022, the Department received an allegation that staff is allowing C1 to be bullied by other minor(s) in care. Confidential interviews stated C1 was not bullied however, C1 called law enforcement on multiple occasions stating C1 was being hurt. (see continuation form LIC9099-C dated 12/02/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 12/02/2022

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

met_with: Antonio Tucker


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Based on confidential interviews, the allegation that S1 handled C1 in a rough manner is SUBSTANTIATED because the preponderance of evidence standard has been met. This posed an potential Health, Safety, or Personal Rights risk to children in care, the facility will be cited for violating Interim Licensing Standards STRTP, Article 06. Continuing Requirements, Personal Rights (c)(10)To be accorded dignity in their personal relationships with staff and other persons. An exit interview was conducted, and plan of corrections was developed with Deanna Mellos, Director and Amber Jansen. A copy of this report and appeal rights were provided to Deanna Mellos, Director.

Investigation Findings:
13On October 12, 2023, at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection at the facility's corportate office. The purpose of the inspection is to deliver the findings for the above allegation and met with Deanna Mellos, Director. LPA Jauregui conducted an inspection of the facility on August 2, 2023, and no deficiencies were noted. During the investigation, LPA conducted three staff (S1-S3) interviews and three client (C1-C3) interviews. On July 28, 2023, Community Care Licensing (CCL) received the allegation that staff handled minor in a rough manner. Confidential interviews indicated C1 had escalated inside the facility, went outside to the front of the facility, and began hitting staff's vehicle with their casted arm. To prevent C1 from causing damage to staffs vehicle S1 grabbed C1's arm to move C1 away from the vehicle causing C1 to fall to the ground. S1 grabbing C1's arm leading C1 to fall to the ground did not accord C1 dignity in their personal relationships with staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 10/12/2023

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0

met_with: Deanna Mellos, Director

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Continued... Based on confidential interviews the allegation alleging Staff made an inappropriate comment to youth on multiple occasions may have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Antonio "Shawn" Tucker.

Investigation Findings:
13On January 23, 2024, at 8: AM, Licensing Program Analyst (LPA), Jacob Salem met with Antonio "Shawn" Tucker, Adminstrator of First Step Treatment Home to deliver the finding for the above stated allegation. LPA Salem conducted an inspection of the facility on 10/23/23 and no deficiencies were observed. LPA Salem conducted interviews with Staff (S1-4) and Clients (C1-C6). In addition, LPA reviewed C1's Appraisal/Needs and Services Plan and Child and Family Team meeting notes. On October 16, 2023, Community Care Licensing (CCL) received an allegation alleging Staff made an inappropriate comment to youth on multiple occasions. Specifically, it was reported that S2 called C1 a "bitch" repeatedly during the morning of 10/13/23. Confidential interviews revealed conflicting statements of whether S2 used profanity towards C1 and what language S2 specifically used. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: First Step Treatment Homefacility Number: Visit Date: 01/23/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32continued... Based on confidential interviews the allegation alleging Staff made an inappropriate comment to youth on multiple occasions may have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Antonio "Shawn" Tucker. SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Antonio "Shawn" Tucker, Administator


raw_content:
Narrative:
...CONTINUED A conflicting confidential interview disclosed that S1 and S2 did not yell at or approach C1 aggressively during this incident, but S1 did get in C1's face in a threatening manner on separate occasions. Confidential interviews indicate that S1 "matches clients' energy" and goes "chest to chest" with clients when they are escalated. Conflicting confidential interviews indicates that C1 would get in S1's face while living at the facility, and that S1 does not yell at clients or make them uncomfortable. Confidential interviews and a record review of special incident reports reveal that C1 became escalated during a therapy session with S2, leading to C1 punching out the kitchen window and being placed on a psychiatric hold. A confidential interview indicates that S2 was heard yelling back and forth with C1 during the therapy session and calling C1 a liar. A conflicting confidential interview indicates that S2 was using an assertive tone rather than yelling and was instructing C1 to leave their office for being vulgar and unruly. A confidential interview with C1 indicates that S2 treated C1 respectfully during the therapy session. Confidential interviews indicate that S2 is respectful towards clients during therapy sessions and has not been seen yelling at or calling clients names. Based on confidential interviews and records reviewed, the allegation that staff members (S1 and S2) spoke inappropriately to youth in care (C1) is unsubstantiated. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Antonio "Shawn" Tucker, Facility Manager.

Investigation Findings:
13On July 11, 2024 at 11: AM, Licensing Program Analyst (LPA) Jacob Salem met with Antonio "Shawn" Tucker, Facility Manager of First Step Treatment Home to deliver the findings for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 1/23/2024 at 8: AM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C4), Staff (S1-S5). LPA Salem obtained and reviewed pertinent records. On January 19, 2024, Community Care Licensing (CCL) received an allegation that staff members (S1 and S2) spoke inappropriately to youth in care (C1). Confidential interviews and record review of special incident reports indicate that C1 became escalated during a house meeting by threatening staff and peers. A confidential interview indicates that S1 and S2 responded by yelling in C1's face, causing C1 to escalate further. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: First Step Treatment Homefacility Number: Visit Date: 07/11/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED A conflicting confidential interview disclosed that S1 and S2 did not yell at or approach C1 aggressively during this incident, but S1 did get in C1's face in a threatening manner on separate occasions. Confidential interviews indicate that S1 "matches clients' energy" and goes "chest to chest" with clients when they are escalated. Conflicting confidential interviews indicates that C1 would get in S1's face while living at the facility, and that S1 does not yell at clients or make them uncomfortable. Confidential interviews and a record review of special incident reports reveal that C1 became escalated during a therapy session with S2, leading to C1 punching out the kitchen window and being placed on a psychiatric hold. A confidential interview indicates that S2 was heard yelling back and forth with C1 during the therapy session and calling C1 a liar. A conflicting confidential interview indicates that S2 was using an assertive tone rather than yelling and was instructing C1 to leave their office for being vulgar and unruly. A confidential interview with C1 indicates that S2 treated C1 respectfully during the therapy session. Confidential interviews indicate that S2 is respectful towards clients during therapy sessions and has not been seen yelling at or calling clients names. Based on confidential interviews and records reviewed, the allegation that staff members (S1 and S2) spoke inappropriately to youth in care (C1) is unsubstantiated. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Antonio "Shawn" Tucker, Facility Manager. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
...CONTINUED However, a conflicting confidential interview stated that after attempts at redirection failed, S1 tried to position themself in front of the door, which inadvertently struck S1's foot. As a result, C1 took a step back, but the door did not hit C1. A confidential interview with C1 indicated that S1 did put their foot in the door, but the door did not hit C1. Other confidential interviews with witnesses present during the incident indicated that although S1 did push back on the door as C1 was closing it, C1 was not hit by the door and was not injured during or after the incident. During an inspection of C1's bedroom door, LPA Salem observed two medium-sized holes toward the bottom on the bedroom side of the door. Confidential interviews and a review of an incident report suggest that C1 barricaded themself in the bedroom after the back-and-forth with S1 by pushing the bed against the door, which may have caused the holes. Additionally, confidential interviews indicated that S1 is not perceived as aggressive or threatening toward clients when they are misbehaving or not following instructions. Based on confidential interviews and records reviewed, the allegation that Staff (S1) engaged in an inappropriate interaction with a youth (C1), resulting in the youth (C1) getting hit by a door is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to D'Andre James, Administrator.

Investigation Findings:
13On September 6, 2024 at 4: PM, Licensing Program Analyst (LPA) Jacob Salem met with D'Andre James, Administrator of First Step Treatment Home to deliver the finding for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 3/5/2024 at 3: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C5), Staff (S1-S4), and a Court Appointed Child Advocate. LPA Salem obtained and reviewed pertinent records. On February 28, 2024, Community Care Licensing (CCL) received an allegation that Staff (S1) engaged in an inappropriate interaction with a youth (C1), resulting in the youth (C1) getting hit by a door. It was reported that S1 placed their foot in C1's door while C1 was closing it, causing the door to bounce back and strike C1. A confidential interview indicated that after a back-and-forth exchange involving C1 slamming and S1 opening the bedroom door, reportedly, S1 admitted to pushing the door, which hit C1 and caused C1 to lose balance. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: First Step Treatment Homefacility Number: Visit Date: 09/06/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED However, a conflicting confidential interview stated that after attempts at redirection failed, S1 tried to position themself in front of the door, which inadvertently struck S1's foot. As a result, C1 took a step back, but the door did not hit C1. A confidential interview with C1 indicated that S1 did put their foot in the door, but the door did not hit C1. Other confidential interviews with witnesses present during the incident indicated that although S1 did push back on the door as C1 was closing it, C1 was not hit by the door and was not injured during or after the incident. During an inspection of C1's bedroom door, LPA Salem observed two medium-sized holes toward the bottom on the bedroom side of the door. Confidential interviews and a review of an incident report suggest that C1 barricaded themself in the bedroom after the back-and-forth with S1 by pushing the bed against the door, which may have caused the holes. Additionally, confidential interviews indicated that S1 is not perceived as aggressive or threatening toward clients when they are misbehaving or not following instructions. Based on confidential interviews and records reviewed, the allegation that Staff (S1) engaged in an inappropriate interaction with a youth (C1), resulting in the youth (C1) getting hit by a door is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to D'Andre James, Administrator. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: D'Andre James, Administrator