summary: Facility Evaluation

raw_content:
Narrative:
On August 23, 2023, at 9: AM a virtual informal office conference was held via Microsoft Teams with the Creekside Short-Term Residential Therapeutic Program (STRTP). The following people were in attendance: Community Care Licensing (CCL) Regional Manager (RM) LaCresha Cook, Licensing Program Manager (LPM) Abdoulaye Traore, Licensing Program Analyst (LPA) Rafael Enriquez, CDSS Rates Consultant, Rates Oversight Unit, System of Care, Carrie Salisbury, Staff Services Manager II John Sanfilippo, CDSS, Rate Analyst, Rates Oversight Tera Tapp, CFS SB County, Manager PRD Ana Del Nogal, Department of Health Care Services (DHCS) Staff Service Manager Andrea Bluford, DHCS Analyst Gabriel Pacheco, DHCS Analyst Steve Conn, DHCS SSMI David Gutierrez, Deputy Director SB County CFS Nancy Satterwhite, Supervisor CFS San Bernadino County Hannah Gutierrez, System of Care Branch Alicia Bernstein, County Social Worker Simika Jones, CDSS CCR SSA (Rates Analyst) Brandy Crosby, Social Services Practitioner (SSP) San Bernardino County Children Family Services (CFS) Amy Mierzwik, Admin. Analyst - Riverside Jenell Ross, CFS SB Joshua Kennedy, CDSS, Provider Development Unit Shamika Payne, PM II DBH San Bernardino Dianne Wolkenhauer PhD, Staff Service Analyst Marjana Jackson, Hannah Gutierrez, Joshua Kennedy, AGPA Ansar Muhammad, Creekside Program Consultant Adri Vermilion, Program Supervisor Elizabeth Pryer, Licensed Marriage and Creekside Family Therapist (LMFT) Shantel Wilson Mcgee, Creekside Board Member Gabriel Hernandez, and CEO Creekside Daryl Monteilh. The following information was discussed: · Lack of Medi-Cal Certification · Lack of Mental Health Program Approval · Possible Application Withdrawal continues on page The summary of the meeting included a discussion regarding the above concerns. At the beginning of the discussion, Licensing Program Manager (LPM) Traore explained the reason for the meeting and explained that the meeting would be a collaborative meeting. During the discussion, LPM asked CEO Darryl Monteilh of the STRTP for update regarding the Mental Health contract with San Bernardino County as the Department received information that STRTP is still in process of getting his mental health contract executed with DBH. Diane Wolkenhauer from the Department of Behavioral Health (DBH) reiterated that the application was approved but the contract has not been executed yet as today 08/23/2023. Dianne added that she didn't know when the contracted will be executed, however, Medi-Cal certification will still need to go through a process, and she couldn't say if it would be done by September 03, 2023. RM Cook indicated CCL's concerns regarding the above-mentioned issues and asked DHCS if the facility would be able to meet all requirement and be approved before the expiration of the provisional license on 09/3/2023. David Gutierrez, DHCS SSMI stated that the STRTP's MHPA application was received on 08/16/23 and assigned to Analyst Stephen Conn. The application still needs a full review, feedback, corrections and onsite inspection. David Gutierrez stated that this process was unlikely to be completed within one week. David Gutierrez added that Med-Cal Certification needed to be submitted along with the application which was not included with the application submitted on 08/16/2023. David Gutierrez stated they should not be pressured to approve a facility that treats children in 7 days. David Gutierrez invited Gabriel Pacheco to provide information. Gabriel Pacheco stated that the first application was denied in February of 2023 and that a new application was finally received and assigned on 08/16/23. David Gutierrez stated that Medi-Cal Certification and contract must be in place in order to approve the MHPA. Regional Manager (RM) Cook asked CEO Darryl Monteilh what his contingency plan was if it were not to be able to receive MHPA before the deadline. Regional Manager (RM) Cook stated options to use and guided STRTP members to make decisions whether to withdraw the STRTP application and be able to re-apply within the same year or he could apply for a different kind of facility as CCL will not be able to extend the provisional license after 24 months. Regional Manager (RM) Cook told CEO Darryl Monteilh that he needs to have a contingency plan so that social workers can take care of what they need to do for the children. continues on page CEO Darryl Monteilh stated he preferred using all his resources first in attempt to be approved before the deadline, however, if he didn't get to achieve his objective, he will withdraw his application and re-apply immediately. He indicated that he has no interest applying for another type of facility and he would like the team to expedite his application if he was to re-apply. LPM Traore stated that the application process could be much faster but that STRP application will need go through a full review. LPM Traore stated if he applies again, he would get a new license and that he needs to address the changes the agencies and department that has previously worked on his application LPM Traore advised CEO Darryl Monteilh to send the closure plan to CCL by August 30, 2023. Nancy Satterwhite commented that if the facility were to close that it would be a great impact to the children in placement at Creekside. She stated that we should try and help Creekside. CEO Darryl Monteilh asked for all hands-on deck. CEO Darryl Monteilh stated that if he chooses to submit his withdrawal, he will submit his application right away. LPM Traore stated that if CCL didn't receive a closure plan and the application withdrawal notification by August 30, 2023, the STRP application will be denied on September 3, 2023 at the expiration of the provisional license. After completion of the conference, LPM Traore thanked the facility representatives and all attendees. A copy of this report was emailed to CEO Daryl Monteilh for signature. Original signed reports will be placed in the facility file.

met_with: Creekside CEO Daryl Monteilh


state: CA

facility_name: CREEKSIDE STRTP

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas conducted a case management inspection June 27, 2024, at 9:30 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 6 out of 6 youth files were reviewed. In the inspection, 3 out of Direct Care Staff and 0 out of 6 youth were interviewed (See the Confidential Names List, LIC 811, dated June 27, 2024). The Plan of Operation including policies and procedures were reviewed. Minutes from the Critical Incident Annual Review and Analysis meeting related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the youth needs and service plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with the staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Rosas observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance with their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Shanikka Fields, Program Manager.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Darryl Monteilh, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/24/2024, LPA Joon Choi visited the facility and met with Residential Treatment Counselor Raven Kratzer. LPA explained the purpose of the visit was to meet with a client regarding two complaints from their previous facility. During the visit, LPA interviewed one client.

met_with: Raven Kratzer, Residential Treatment Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On July 29, 2024 at 9: AM, Licensing Program Analyst (LPA) Rachel Vanegas arrived at Creekside Short-Term Residential Therapeutic Program (STRTP) to conduct an annual inspection of the facility. LPA was greeted by the morning facility manager, Rayven Richards. LPA toured and inspected the facility inside and out with Rayven Richards. The facility grounds were clean and free of debris or any observable hazards. There was adequate indoor and outdoor activity space for the residents in care. The facility's activity room contained toys, books, board games, art supplies, and other recreational indoor activities accessible to the residents in care. All facility smoke detectors and carbon monoxide detectors were in appropriate working order. There are two fire extinguishers, one at the entrance of the facility and one in the staff office, both were observed to be fully charged and in working condition. The facility maintains an adequate supply of perishable and non-perishable foods and had a posted menu for breakfast, lunch, and dinner that LPA reviewed in the kitchen. All required forms were posted throughout the common areas of the facility including the Grievance Procedures, Visitation Policies, Personal Rights and Foster Care Ombudsman posters. Medications were double locked and centrally stored in a locked cabinet in the staff office. Contraceptives are adequately stored and secured for residents in care in the staff office medication cabinet as well. The facility kitchen knives are stored in a locked cabinet in the staff office and are only accessible to clients with staff supervision during meal preparation. The hot water was measured in the kitchen and registered at 112.8 degrees F. The cleaning chemicals and laundry detergent are stored in a locked closet in the facility garage where the client's do not have access. LPA inspected four client bedrooms and observed that six out of six individual beds were appropriately clean and had linens, pillows, comforters, and mattresses in good repair. Four out of four bedrooms have adequate storage space for the client's belongings in drawers and a bedroom closet. The facility has three restrooms, two are utilized by clients and one is utilized by staff. **Continued on LIC 812-C** The hot water in the restrooms were within the appropriate range of 105 degrees to 120 degrees Fahrenheit, 117.5 degrees F. The dining room has a table with adequate seating for the current census. The facility outside grounds were also inspected and were observed to be clean and free of debris. There is a swimming pool located in the backyard of the facility. The pool is surrounded by a wrought iron fence that measured to be 5 feet tall with a gate that self-latches and opens outward. The facility has a dumpster located at the end of the facility driveway that has an adequate lid to secure excess facility trash. LPA reviewed the Physical Plant, Operational Requirements, Disaster Preparedness, and Core Therapeutic Services. Due to time constraints, LPA will return to complete the inspection at a later date. Based on observation and record review, all documentation pertaining to these areas of the inspection were provided. One technical violation is issued for Interim Licensing Standard (ILS) 87063(a)(9) to the facility for not ensuring that board of director meeting minutes are kept and retained as a permanent record. LPA conducted one client interview. An exit interview was conducted and a copy of this report and appeal rights were reviewed and provided to the Program Supervisor, Shanikka Fields.

visit_type: Annual

met_with: Rayven Richards - Facility Manager Shanikka Fields - Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On August 7, 2024, at 12: PM, Licensing Program Analyst (LPA), Rachel Vanegas arrived unannounced at Creekside Short-Term Residential Therapeutic Program (STRTP). LPA met with Shanikka Fields - Program Supervisor, to continue an annual inspection that was initiated on July 29, 2024 when LPA conducted a review of the Physical Plant, Operational Requirements, Disaster Preparedness, and Core Therapeutic Services. During today's inspection, LPA completed the review of Staffing Records, Client Records, and Emergency Intervention Plan. LPA reviewed five staff files, Staff 1(S1), Staff 2(S2), Staff 3(S3), Staff 4(S4), and Staff 5(S5) and four client files, Client 1(C1), Client 3(C3), Client 5(C5), and Client 6 (C6). Five out of five staff records reviewed contained required and pertinent documents such as duties of the employee, criminal record clearance, health screening clearance, etc. Four out of four client files reviewed contained required and pertinent documents including: admission agreements, medical consent forms, personal rights forms, etc. However, four out of four client files reviewed, did not have a documented medical assessment tuberculosis (TB) test result on file within 30 days of placement. Based on observation and record review, the facility is being cited one Type B violation in accordance with California Code of Regulations (CCR) (Title 22) 80069(c)(1) for not having the results of medical/TB examination on file for C1, C3, C5, or C6 prior to or within 30 days of admission to the STRTP. Additionally, the facility is being issued one technical violation in accordance with Interim Licensing Standards (ILS) 87070(c)(1) for the Needs and Services Plan (NSP) missing signatures from the authorized representative for C1, C3, C5, and C6. As part of the annual inspection, LPA conducted two staff interviews. An exit interview was conducted and a copy of this report, LIC 811 (Confidential Names List), and appeal rights were reviewed and provided to the Program Supervisor, Shanikka Fields.

met_with: Shanikka Fields - Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA), Michael Almaraz, conducted an unannounced case management inspection on June 6, 2025, at 10: AM. During the inspection, LPA met with Creekside STRTP Program Supervisor Shanikka Fields. The purpose of the inspection was to address information obtained during a review of an incident that occurred on or around April 28, 2025. LPA inspected and reviewed the facility file on May 7, 2025, at 12: PM. During LPA's inspection LPA observed S1 on facility grounds. During LPA's record review of the facility file it was noted that the facility did not have a criminal record clearance as specified in Section 80019(e)(2) for S1 listed on confidential names list (LIC 811) dated June 6, 2025. Facility will be cited for violation of Title Regulations 80019(e)(2) Criminal Record Clearance. Based on LPA's record review and observation the preponderance of evidence standard has been met that the facility did not obtain a criminal record clearance for S1. An exit interview was conducted, a copy of this report along with LIC 809D, LIC 421B, LIC 811, and appeal rights were provided to Shanikka Fields.

met_with: Shanikka Fields


summary: Facility Evaluation

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Narrative:
On January 7, 2022 at 10: AM, LPA Shanae Pharaoh, conducted a case management visit regarding locking down the facility and dropping clients off at the county. When LPA arrived at the facility, there was only one staff and five clients present at the facility. One staff, two clients and the Administrator were interviewed. LPA received information that the facility was not on lock down and they only lost community passes for 24 hours. LPA received information that the privileges are taken away on individual bases due to behavior and on one day particular day most of the clients in the facility were displaying behavior that resulted in lost privileges. LPA also received information that some of the girls privileges were taken away who felt that they should not have gotten taken away. Administrator stated there was marijuana coming from one of the girls rooms who only was in a one bed and there was no one else in the room. Administrator stated everyone except for two clients lost their privilege that day due to all of their behaviors. LPA was also informed that they now have to have bank cards because some people were buying drugs with the cash. Administrator stated they still get their allowance when they are supposed to but the drug purchasing was an issue when they went on community passes. LPA received information that those who do not have behaviors do not ask for community passes, but if they asked they did they would have been given a pass. Administrator stated although they inform them they lost community pass privileges they are still allowed of out the facility. LPA informed Administrator to avoid using the word lock down and to describe the privilege that was lost and whom for when sending the incident reports. LPA also discussed ensuring they are not taking away privileges for all girls and documenting their behaviors. The facility is being cited for Interim Licensing Standards, Chapter 7.5, Version 4, Section 87065. Direct Care Staff/Child Ratios on the LIC 809D. A copy of this report was reviewed and provided to the facility Administrator, Erin Franco.

met_with: Administrator - Erin Franco


summary: Facility Evaluation

raw_content:
Narrative:
On March 16, 2022 at 1: PM, Licensing Program Analyst (LPA) Shanae Pharaoh conducted an unannounced case management inspection at the facility. LPA met with Program Supervisor, Yanique Bonnert . The purpose of the case management inspection was to address an incident that occurred on or around 01/07/2022 and was reported to Community Care Licensing on (CCL). Prior to the inspection, LPA conducted two staff interviews regarding the incident. During the investigation, LPA was informed that a staff left the facility due to feeling unsafe and uncomfortable at the facility due to a client having COVID 19. Confidential interviews stated that S1 informed the Administrator that S1 did not feel comfortable at the facility and would not be staying for the shift. Confidential interviews stated that the Administrator said it was too late of a notice to get a new staff on duty. Confidential interviews stated S1 was informed that the the CEO was not available and was told to go into the office, put a mask on and do not come out. Confidential interviews stated, S1 left 15 minutes after the shift started and S1 informed the Administrator that S1 was leaving. Confidential interviews stated the Administrator was informed that there was no staff at the facility at 1:00AM. The facility is being cited for 87065(g) Personnel Requirements on the 809D An exit interview was conducted and a copy of this report was provided to Program Supervisor, Yanique Bonnert.

met_with: Program Supervisor, Yanique Bonnert


summary: Facility Evaluation

raw_content:
Narrative:
On June 16, 2022 at 10:11AM, Licensing Program Analyst (LPA), Shanae Pharaoh, conducted an unannounced case management inspection at the facility. LPA met with Program Supervisor, Elizabeth Pryer and was informed about the reason for the inspection The purpose of the case management inspection was to address deficiencies regarding incident reporting and Administrator. LPA received information that facility had a change in Administrators that was not relayed to The Department. LPA received the LIC 500 from the facility that further confirmed that there was an unapproved change in Administrators. Interviews conducted stated that S1 was the current acting Administrator. LPA also received information that the facility did not send a serious incident report (SIR) regarding a client going to the emergency room. LPA contacted the facility to request the SIR. S1 stated she sent the SIR to the authorized representative but not to the Department. On June 13, 2022, LPA received 18 late SIRs including Law Enforcement contact reports. LPA informed the facility of the reporting requirements and the need for any change in Administrators to be approved by the department. Based on interviews and record review, the facility is being cited on Interim Licensing Standards, Version 4, 87061(j) Reporting Requirements and Administrator Qualifications and Duties on LIC D

met_with: Program Supervisor - Elizabeth Pryer


summary: Facility Evaluation

raw_content:
Narrative:
On July 20, 2022, at 11:38 am Licensing Program Analyst (LPA), Nicole Strickland and Rafael Enriquez, met with Creekside Short Term Residential Therapeutic Program (STRTP) Administrator (ADM) Daryl Monteilh to deliver a case management deficiencies report. According to information obtained by Community Care Licensing (CCL) the facility did not ensure reporting requirements were followed when Child #1 (C1) and Child #2 (C2) left the facility on January 25, 2022 and ended up in a motel with unknown individuals. Record review revealed C1 and C2 returned the facility at 6:24 pm on January 25, 2022 packed up their things and stated that they will be back for the rest of their items. Record review revealed staff did attempt to talk to C1 and C2 however, attempts were ignored by C1 and C2. Record review was unable to provide evidence of a Serious Incident Report (SIR) being submitted to CCL and C1 and C2's authorized representatives as required by California Code of Regulations (CCR) regulation 80061(b)(E) REPORTING REQUIREMENTS (b)(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of a client. A copy of this report was discussed and provided along with appeal rights to Creekside Short Term Residential Therapeutic Program (STRTP) Administrator (ADM) Daryl Monteilh.

met_with: Daryl Monteilh


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA's) Leslie Covarrubias and Joon Choi on April 10, 2023 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA's Covarrubias and Choi met with Elizabeth Pryer, Program Supervisor and inspected the facility inside and out. LPA's reviewed three of child's records and three of staff personnel files on site at the facility. LPA's reviewed three of child's psychotropic medications and medication records. LPA's interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA's interviewed zero of children currently prescribed psychotropic medication. Two clients refused and one client is not able to be interviewed. During the inspection the LPA's observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA's provided a copy of this licensing report to Elizabeth Pryer, Program Supervisor

met_with: Elizabeth Pryer, Program Supervisor


facility_name: CREEKSIDE STRTP II

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Daniel Mena conducted a technical assistance meeting virtually via Teams with Creekside II Short Term Residential Therapeutic Program (STRTP) CEO, Darryl Monteilh and Erin Franco. Present at the meeting was System of Care Branch Manager, Marjana Jackson and Licensing Program Manager, Nicole Strickland . The Purpose of the meeting was to discuss and review the following pending Plan of Operation (POO) and Program Statement (PS) revisions: Plan of Operation Section A. Purpose and Goals 1. Purpose on page 2 and again on page 8? Combine 2. Virginia Satir's Theories Page 5. What is that? Summarize 3. Brene Brown's Same Resilience Theory? Page Summarize 4. Page 10 not necessary in this section. Section B. Administrative Organization 1. Pg. Facility administrator duties. On page 22 not necessary if covered later on in job description forms. 2. Did not see Administrator certificate 3. Designated administrator substitute when they are absent. Did not see addressed Section C. Facility Sketched 1. Which room would be designated as the NMD room if necessary? 2. Indicate 2 clients per bedroom Section D. Staff Plan 1. Explain how the staff training plan is appropriate to meet the needs of the staff, and the population served. Page 3 of 16 2. Explain how the staff training plan will provide staff with the knowledge, skills, and support to ensure the health and safety of youth in care. 3. Please include information about how to engage members of the child's family and community, including parents, siblings, caregivers, other relatives and nonrelated extended family members, and other supportive adults consistent with law and any applicable court orders. 4. Please explain HOW the training plan is designed to ensure: • cultural competency and sensitivity including but not limited to best practices for providing adequate care, services, and supports for children across diverse ethnic and racial background, as well as children identifying as lesbian, gay, bisexual, transgender, or nonbinary. • Methods to behaviorally support youth are appropriate for children impacted by trauma or child abuse and neglect. • Best practices for addressing the permanence, well-being and educational needs of youth including children with disabilities. 5. The comprehensive staff training plan is missing the following: • This section mentions 40 hours of job shadowing and nothing else. Job shadowing must follow section 87065.1(d)(1)(D) and 87065.1(c)(2)(A). • Missing 8-hour training assessment. • The 16-hour training assessment mentioned does not follow section 87065.1(d)(2)(B). • Missing required training topics for Direct Care Staff and Facility Manager. • Please identify the additional 16 hours of training that new staff will complete within 12 months of being hired. • It's mentioned that 20 hours of the 40 hours of annual training will consist of work from an entity not affiliated with the STRTP. However, it is not clear what that training is. Please indicate the training topics that will be from another entity. • Missing the designated employee training related to application of reasonable and prudent parent standard. • Need 2025 updated training schedule. Section F. Administrative Policies and Procedures 1. Conflict of interest, self-dealing, segregation of duties and less-than-arms-length transactions; Page 4 of 16 2. Internal controls, including, but not limited to, financial accounting, reconciliations, financial security measures, disbursements, petty cash and financial record keeping. • Did not see this addressed Section G. Admission Determination Procedures 1. Determination procedures do not demonstrate the willingness and capacity to assess and determine the appropriateness of placement within the program, consistent with the population to be served, on an individualized basis for each child referred by the placing agency. 2. Explain in detail how the determination procedures will consider the child's needs and strengths, the likelihood that the child will benefit from the program, and the extent to which the child's needs are in common with the existing client population. 3. Determination procedures do not include an explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics, including how the licensee defines these characteristics for the purposes of assessing appropriateness of fit: • Frequent runaways • Gang-related activity • Firestarting • Sexually assaultive behaviors • History of Commercial Sexual Exploitation • Substance abuse 5. Missing a statement that the list of behaviors or characteristics (above list) shall not be utilized as the sole basis to determine the appropriateness of placement and/or deny admission. 6. Determination procedures shall specify the following: (A) The timeframe for and manner of response to referrals for placement, as set forth in ILS Section 87068.05(c)(4): • The facility shall establish timeframes for response to the county placing agency regarding referrals for placement. • The established timeframes must include, but are not limited to, an initial response period in which the facility accepts, denies, or requires more information for the consideration of the referral for placement and; Page 5 of 16 • A final response period in which the facility accepts or denies the referral for placement. • The facility's initial response period shall not exceed 5 days following the receipt of referral for placement. (B) The minimum information that is necessary for a placing agency to provide to the STRTP in order for placement to be considered. 7. Missing elevated review procedures 8. If interviews are conducted during the admission process, need to include a statement that the interview cannot be used to determine placement appropriateness or deny admission for placement. 9. Missing referral documentation process. 10. Missing procedures for when the STRTP determines that the program is not capable of meeting the youth's needs with and without additional services and/or support. 11. There's no language affirming that admission decisions will not be based on race, ethnicity, gender identity, sexual orientation, or disability, which is a required element. 12. Which staff member will be responsible for reviewing the referral? Section H. Intake Policies and Procedures 1. This section mentions Admission Determination Procedures, which should be captured in section G. This section must include intake procedures for when the youth has been accepted for nonemergency placement in the STRTP. Please remove determination procedures and keep relevant information in this section to avoid confusion. Refer to PINs attached. 2. Missing the initial crisis management assessment as set forth in ILS Section 87068.1(d), which include, but are not limited to, how the component/s of the assessment that include input from the child shall be conducted in manner that is consistent with trauma-informed practices and the requirements in ILS Section 87078.2. • Assessment provisions and input from youth and family members. • Assessment must be used to inform the emergency interventions used on that specific youth. 6. Emergency placement procedures are not complete. 7. If orientation interviews are conducted as part of intake procedures, need to provide policies and procedures that demonstrate and provide descriptions and details that the purpose of the orientation interview is to support the youth's transition into placement. Section 87068.1(f)(1) through (2). Page 6 of 16 • In this section, I did not see a statement of the policies and procedures regarding intake of children and NMDs includes procedures for medical assessment, including TB results Section I. Admission Agreement 1. Typos page 98 2. Did not see procedures for modifying the agreements. 3. Did not see written statement regarding the type(s) of emergency interventions the licensee has been approved to use in the Admission Agreement Section J. Removal or Transfer Policies and Procedures 1. Missing procedures for removal and/or transfer of children and NMDs as described in Section 87068.1: • After program goals have been reached 2. Missing procedures that include a description of how the licensee will mitigate against potential impacts to a child as a result of removal or transfer, including but not limited to how the licensee will assist in preventing delays or gaps in delivery of services, types of trauma-informed support and transition services to be provided, and best practices for staff communication with the child during the transition 3. Procedures do not ensure that children and their authorized representatives are informed of removal/transfer policies in an age and developmentally appropriate manner. 4. Need a statement that the STRTP will not transfer the youth unless prior written approval of the transfer has been obtained. 5. Missing section 87068.4(c)(1)-(2). 6. Missing section 87068.4(e)(1)(A)-(F). 7. What are the "additional community-based supports and services" that the Director shall request? 8. Since STRTP will be operating under a provisional license, the Mental Health Head of Service cannot sign the statement providing the reason for the removal request. 9. Need a statement indicating that the request for placement change will not be initiated prior to the first update of the youth's NSP. 10. Missing procedures for notifying the youth that a notice to remove them has been issued. See section 87068.4(e)(2)(E). Page 7 of 16 11. Missing emergency removal procedures (there's a brief mention, but no procedures). 12. Removal procedures for NMDs are mentioned twice and are incomplete. 13. The notice that is given to the county for when the STRTP determines it cannot meet the needs of the youth is missing provisions listed in section 87068.4(e)(2)(A)(1)-(6). Section M. Consultants and Community Resources Utilized 1. Provide a list of consultants and community resources utilized by the facility as part of its program. 2. Provide a statement regarding how the facility will engage, coordinate, and contract with the consultants and community resources, which shall include but is not limited to, tribal partners,county placing agencies, and mental health providers. Section N. Trauma-Informed Intervention and De-Escalation Techniques 1. This section is vague. While it does mention trauma-informed and evidence-based interventions, there's no mention of de-escalation techniques that will be used to promote the safety of all individuals in the facility, including but not limited to children or NMDs who have a propensity for behaviors that result in harm to self or others. The trauma-informed and evidencebased interventions must be applied to the population this STRTP intends to serve. • Only saw definitions and not how it is implemented. Did not see any de-escalation techniques, including to those with a propensity to self-harm. Section Q. Continuous Quality Improvement (CQI) 1. This section repeats the requirements for this section but does not explain HOW the requirements will be met. 2. Who is part of the QI team? 3. Does not include frequent review, documentation and if necessary adjustment of the youth's NSP. 4. Explain in detail how CQI will incorporate active inclusion and participation of staff, children/NMDs, families, and community resources, including a description of a process for getting direct input from the children, as age appropriate, to inform program development and improvement Page 8 of 16 5. Explain in detail how the CQI will adopt outcomes, indicators, and practice standards, including outcomes associated with trauma-informed and culturally relevant services. 6. Missing collection of qualitative and quantitative data and information related to identified outcomes, indicators, and practice standards. 7. Explain how the facility will review, analyze, and interpret the data 8. Explain how the facility will take the data to inform and improve policies, practices, and programs 9. Missing procedures for evaluation of the STRTP's outcomes and results 10. Explain how CQI program will be culturally relevant, trauma-informed, and age and developmentally appropriate. 11. Explain how the facility shall work collaboratively with the Department on the CQI program by being timely and responsive to Department meeting requests, correspondence, and other similar requests by the Department related to CQI. 12. What role will the Board of Directors play in the CQI process? Program Statement 1. Population to be Served 1. Since the facility intends to serve NMDs, the program statement needs to include a description of programs or services to be provided consistent with assisting an NMD in preparing for the transition to independent living. 2. Please indicate if the facility intends to serve children or NMDs with special health care needs. If so, include a statement that it meets all requirements for a specialized STRTP, as defined in ILS Section 87001(s)(5), a description of its program or services to be provided to this population, and a description of how the programs and services meet the requirements as specified in the ILS including, but not limited to, ILS Sections 87010.2, 87064.1, 87065.6, 87066.1, 87068.12, 87069.2, 87070.2, 87072.3, and 87087.1. 3. The program statement does not include a description of how the facility programs have the ability to support: I. The individual needs of children, NMDs, and their families, with short-term, specialized,trauma-informed, and intensive treatment, including, but not limited to, treatment that implements child-specific short-and long-term needs and goals identified by the qualified individual's assessment of the child • A description of programs or services to be provided consistent with assisting an NMD in preparing for the transition to independent living. Not covered or addressed sufficiently. Page 9 of 16 3. Transportation Arrangements Who will be the primary person/position in charge of vehicle maintenance requirements.? 5. Trauma Informed Interventions and Treatment Practices 1. Demonstrate how the program is trauma-informed by including interventions, practices, services, and supports that recognize and adequately demonstrate how the program addresses each of the following: • Interventions, techniques, and practices that are trauma-informed, culturally relevant, age and developmentally appropriate, as provided by direct care staff to a child or consistent with a child's or NMD's needs and services plan and treatment plan. 2. Missing policies and procedures that include prevention services, interventions, and practices, services, and supports that demonstrate the following: • How observable behaviors will be identified and evaluated to assess the need for services. • How emergency interventions, including early interventions and de-escalation procedures, are trauma-informed; 3. Missing procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma-informed. 4. Missing policies and procedures for collaboration with Child Welfare, Probation, County Mental Health, CFTs, and outside partners to ensure effective and consistent provision of care and services that are trauma-informed. 5. Missing procedures for maintaining consistency with TILPS (when applicable). 6. Licensed Nursing Staff 1. If the STRTP is unable to hire a nurse, what's the plan to ensure there is access to nursing services? 7. Development, Implementation, and Modification of Needs and Services Plan 1. Recommend revising this entire section as it does not adhere to sections 87022.1, 87068. Page 10 of 16 2. Describe the procedures for the development, implementation, and periodic updating of needs and services plan for children and NMDs, that are trauma-informed, culturally relevant, and age and developmentally appropriate, and procedures for collaborating with the CFT that include a description of the following: • This section does not mention the short-and long-term needs and goals of the child or NMD as assessed by the qualified individual under WIC sections 4096 and 11462.01 • Explain how the STRTP will ensure the processes to treatment is consistent with the shortand long-term needs and goals for the child, including as specified in the child's permanency plan • Describe the procedures for the development, implementation, and periodic updating of needs and services plan for children and NMDs, that are trauma-informed, culturally relevant, and age and developmentally appropriate, and procedures for collaborating with the CFT that include a description of the following: • Provide the services to be provided or arranged to meet the short-and long-term needs and goals of the child or NMD as assessed by the qualified individual under WIC sections 4096 and 11462.01 • Explain how the STRTP will ensure the process of treatment is consistent with the short-and long-term needs and goals for the child, as specified in the child's permanency plan • Include the anticipated duration of treatment • Include the process to ensure that consistent progress is made toward the timeframe and plan for transitioning the child or NMD to a less restrictive family environment • Missing procedures to ensure the child or NMD's needs and services plan is consistent with the case plans including the needs as identified by the qualified individual, as developed by the county placing agency and recommendations by the CFT • Missing procedures to support the reasonable and prudent parent standard, as specified in Section 87067 3. The NSP is missing section 87068.2(c)(1)-(3). 4. Missing section 87068.2(d)-(h)(1). 5. Missing section 87068.2(b)(1)-(9). 6. Please provide details for the modifications and refer to section 87068.3(b)-(c). 7. Please note NSP for NMDs differ and should follow provisions listed in section 87068.22(a)- (g). 8. Missing procedures to support the reasonable and prudent parent standard, as specified in Section 87067. Page 11 of 16 8. Planned Activities 1. This section includes activities, but there is no clear plan for the following: • Activities that require group interaction. • Planned recreational activities to encourage socialization. • Educational services and remediation. • Activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's/NMD's needs and services plans • Pre-vocational or vocational counseling. • The development of community support systems for children/NMDs to maximize utilization of non-mental health community services and other resources. • Use of the residential environment to assist children/NMDs in the acquisition, testing, and refinement of community living and interpersonal skills. • Access to computer technology and the internet, consistent with the child's age, maturity, developmental level, court order, and CFT decision. 2. The written plan for activities does not demonstrate that it allows children/NMDs to participate in age or developmentally appropriate extracurricular, enrichment, cultural, and social activities and ensures that the reasonable and prudent parenting standard as specified in Section 87067 will be applied. 3. Please specify if there will be any on-site vocational trainings provided in the facility, including skills taught, goals of the training, hands-on experience received, materials provided, number of hours per day/days per week, and funding. 4. For outdoor activities. Where are some of these places located? Give names of hiking trails & specific parks in the area. 5. Access to computer technology and the internet, consistent with the child's age, maturity, developmental level, court order, and CFT decision. Not addressed. 9. Services During Placement and After Discharge 1. Need to specify the name, location, and services provided by an agency or agencies that STRTP has partnered with, either formally or informally, to provide additional supports and services to families and children, including NMDs during care and post-permanency. Page 12 of 16 2. Since mental health approval has not yet been obtained, provide a detail description of how the STRTP will provide children in its care access to mental health services. 10. Plan for Participation in Child and Family Team ("CFT") 1. Describe the facility's plan for participation in CFTs, including when the provider will request a CFT meeting if needed. 2. Describe how the facility plans to participate in CFT meetings in a manner that is traumainformed, culturally relevant, and age and developmentally appropriate. 3. Explain how the STRTP plans to honor the youth's request for a CFT. 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Services 1. Provide a detailed description of how the facility, in accordance with the child's case plan and the CFT recommendations, will provide for, arrange for the provision of, or assist in, all of the following: • Development of an individualized family-based aftercare support plan that identifies necessary supports, services, and treatment to be provided for at least six months postdischarge as a child moves from the STRTP to a home-based family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. This plan shall be developed, pursuant to WIC section 4096.6, in collaboration with the county placing agency, the CFT, and other necessary agencies or individuals for at least six months post-discharge. • Aftercare services may be provided by the following, including, but not limited to: a STRTP, county placing agency, child welfare agency, probation department, mental health plan, or other agencies or individuals pursuant to WIC section 4096.6. • Documentation of the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). 12. Family and Sibling Participation Page 13 of 16 1. On and after October 1, 2021, a description of how the STRTP will, to the extent clinically appropriate, consistent with any applicable court orders, and in accordance with the child's best interest, do all of the following: I. Document how family members will be integrated into the treatment process for the child, including post-discharge, and how sibling connections are maintained. • Did not see how the outreach is made, including contact information or how the child shall be engaged to determine the preferred family members to interact with. 15. Family Visitation • Should have a process by which staff speak to child to "debrief" and ensure that all went well and clients are not victimized during unsupervised visits or visitations. 16. Personal Rights 1. Describe policies and procedures that demonstrate compliance with personal rights. 2. The procedures do not include the requirement to explain and advise the child and their authorized representative of personal rights at the request of the child, and each time a new right has been added. 3. Missing the language that the personal rights will be explained in a trauma-informed, age and developmentally appropriate manner. 4. Additional trainings after hire? Mention that staff also sign personal rights form. 17. House Rules for Child(ren)/NMDs 1. Provide a description of how the house rules are culturally relevant. 2. Please include that any restrictions on electronics will be in the NSP. 3. Indicate/mention how House Rules shall not violate the personal rights of children and NMDs 18. Positive Discipline Policies and Procedures Page 14 of 16 1. Types of discipline permitted must also include the ones listed in section 87072.1(d)(1)-(5). 2. Need to include a statement that youth will not be subject to a consequence for refusing to take their psychotropic medication. 3. Missing procedures for when a youth is subject to positive discipline. 4. Need to include a statement that calls or threats to call law enforcement are not a form of discipline. 5. Explain how the positive discipline policies will not violate personal rights. 6. This section includes NMDs. Please remove NMDs from this section, as this section does not apply to NMDs. 7. Explain how the positive discipline policies and procedures will be age and developmentally appropriate. 19. Expectations and Consequences for NMDs 1. Need to include a statement that NMD will not be subject to a consequence for refusing to take their psychotropic medication. 2. Need to include a statement that calls or threats to call law enforcement are not a form of discipline. 3. Explain how the positive discipline policies will not violate personal rights. 4. Types of discipline permitted must also include the ones listed in section 87072.11(e)(1)(A)- (B). 5. Missing section 87072.11(b)(1)-(5). 6. Missing procedures for when an NMD is subject to positive discipline. 7. Types of discipline not permitted. Not addressed 8. Provisions for informing staff, NMDs, and the NMD's authorized representative(s) of expectations and consequences policies and procedures; Not addressed 21. Safeguards For Cash Resources, Personal Property, and Valuables • Indicate what procedures are implemented to ensure property, cash and valuables are safeguarded when clients are on AWOL or after clients are removed or relocated to another facility. Page 15 of 16 24. Mental Health Program Approval 1. Explain how the STRTP providing care and supervision to children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered shall make provision for at least monthly consultation from a psychiatrist, or clinical psychologist, or licensed clinical social worker regarding the program of services, or more often as appropriate to the needs of the child or NMD. 25. Food and Nutritional Plan/Sample Menus/Schedule • Procedures on how all staff will be made aware of any special dietary needs due to allergies, medical conditions, religion etc. • Clothing and hygiene needs not necessary for this section 26. Emergency Intervention Plan (Runaway Plan) 1. Explain how the Emergency Intervention Plan is: • Appropriate for the population of the youth served • Appropriate for the staff qualification and staff emergency intervention training • Trauma-informed, culturally relevant, appropriate for the age, size, emotional, behavioral and developmental level of the children and account for the particular traumas of specialized populations, including but not limited to, commercially sexually exploited children. 2. Missing procedures that include and support recognized trauma-informed principles, approaches, and trauma specific interventions, de-escalation and harm reduction techniques. 3. Missing procedures that include descriptions and details in the written procedures to demonstrate how the licensee will ensure the prevention of personal rights violations. 4. Each emergency intervention is missing the following: • A description of each emergency intervention technique, including manual restraints, to be used and in what types of situations they will be used. • Maximum time limits for each emergency intervention technique, not to exceed maximum time limits as specified in Section 87095.22(f). • In what situations each emergency intervention technique is not to be used. • Expected outcome, benefits to the child. Page 16 of 16 5. Specify the behaviors that may require the use of emergency intervention. 6. Missing sections 87095.22(d)(5)-(11). 7. The Manual Restrain Plan is missing sections 87095.22(f)(1)-(7) and procedures for the following: • documenting and maintaining a monthly log of each use of manual restraints, as specified in ILS Section 87095.61(g) • debriefing following a review of the use of manual restraint, as set forth in 87095.68. • accessing community emergency services, including, but not limited to, law enforcement if the use of emergency interventions is not effective or appropriate. • concerning when and how to involve law enforcement in response to an incident at the facility consistent with ILS Section 87072(c)(32). 8. Missing the Emergency Intervention Staff Training Plan. See section 87095.22(g)(1)-(6). 9. There's a brief mention of biannual review but there are no procedures. See section 87095.22(h). 10. There's no mention of the admission agreement. 11. The Runaway Plan does not describe how staff will respond to the following: • Child(ren) outside of the facility property without permission, but who are within view of the staff. 12. Explain how the Runaway Plan is trauma-informed, culturally relevant, appropriate for the age, size, emotional, behavioral, and developmental level of the child(ren), and account for the particular traumas of specialized populations, including, but not limited to, commercially sexually exploited children. 13. The Runaway Plan is missing section 87095.24(c)(4) and sections 87095.24(c)(7)-(9). 14. The Runaway Plan is missing section 87095.24(e)(1)(A)-(C). 15. Intervention plan procedure if multiple children AWOLing? A copy of this report was provided. Mr. Darryl Monteilh stated that corrections would be submitted for review to Licensing Office by November 17, 2025. Corrections made will be highlighted.

met_with: Darryl Monteilh


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Daniel Mena conducted a second technical assistance meeting virtually via Teams with Creekside II Short Term Residential Therapeutic Program (STRTP) CEO, Darryl Monteilh and Erin Franco. Present at the meeting was System of Care Branch Manager, Marjana Jackson and Licensing Program Manager, Nicole Strickland . The Purpose of the meeting was to discuss and review the following pending Plan of Operation (POO) and Program Statement (PS) revisions: Creekside II STRTP Application 2ndReview Plan of Operations Section B. Administrative Organization 1. Did not see Administrator certificate Section C. Facility Sketched 1. Which room would be designated as the NMD room if necessary? 2. Indicate 2 clients per bedroom (Facility sketch/s not included) Section D - Staff Plan 5. The comprehensive staff training plan is missing the following: · Missing 8-hour training assessment. 87065.1(d)(1)(E). · The 16-hour training assessment mentioned does not follow section 87065.1(d)(2)(B). · It's mentioned that 20 hours of the 40 hours of annual training will consist of work from an entity not affiliated with the STRTP. However, it is not clear what that training is. Please indicate the training topics that will be from another entity. · Missing the designated employee training related to application of reasonable and prudent parent standard. Training listed under best practices course title, is this training going to only be focused on NMD's? · Please include information about how to engage members of the child's family and community, including parents, siblings, caregivers, other relatives and nonrelated extended family members, and other supportive adults consistent with law and any applicable court orders. G. Admission Determination Procedures 1. If interviews are conducted during the admission process, need to include a statement that the interview cannot be used to determine placement appropriateness or deny admission for placement. Not addressed. 2. Missing procedures for when the STRTP determines that the program is not capable of meeting the youth's needs with and without additional services and/or support. Not addressed. Procedures do not include language about admission determination if additional services or supports are provided. Section H. Intake Policies and Procedures 1. This section mentions Admission Determination Procedures, which should be captured in section G. This section must include intake procedures for when the youth has been accepted for nonemergency placement in the STRTP. Please remove determination procedures and keep relevant information in this section to avoid confusion. Refer to PINs attached. 2. Missing the initial crisis management assessment as set forth in ILS Section 87068.1(d), which include, but are not limited to, how the component/s of the assessment that include input from the child shall be conducted in manner that is consistent with trauma-informed practices and the requirements in ILS Section 87078.2. • Assessment provisions and input from youth and family members. • Assessment must be used to inform the emergency interventions used on that specific youth. 6. Emergency placement procedures are not complete. 7. If orientation interviews are conducted as part of intake procedures, need to provide policies and procedures that demonstrate and provide descriptions and details that the purpose of the orientation interview is to support the youth's transition into placement. Section 87068.1(f)(1) through (2). • In this section, I did not see a statement of the policies and procedures regarding intake of children and NMDs includes procedures for medical assessment, including TB results Section I. Admission Agreement 1. Did not see written statement regarding the type(s) of emergency interventions the licensee has been approved to use in the Admission Agreement J. Removal or Transfer Policies and Procedures 1. Missing procedures for removal and/or transfer of children and NMDs as described in Section 87068.1: · After program goals have been reached- Not addressed. 2. Missing section 87068.4(c)(1)-(2). Need to clearly explain this requirement. What services and supports will be provided? How will facility work with the placing county or state agency? 3. Missing procedures for notifying the youth that a notice to remove them has been issued. See section 87068.4(e)(2)(E). Notifying youth is listed under emergency removal, should also been mentioned under removal/transfer procedure. 4. The notice that is given to the county for when the STRTP determines it cannot meet the needs of the youth is missing provisions listed in section 87068.4(e)(2)(A)(1)-(6). Required information should be included in written notice. 5. Since STRTP will be operating under a provisional license, the Mental Health Head of Service cannot sign the statement providing the reason for the removal request. 6. Need a statement indicating that the request for placement change will not be initiated prior to the first update of the youth's NSP. 7. Typo- Page 237 "Movie" instead of move. Q. Continuous Quality Improvement (CQI) 1. This section repeats the requirements for this section but does not explain HOW the requirements will be met. 2. Who is part of the QI team? Not clearly indicated. 3. Does not include frequent review, documentation and if necessary adjustment of the youth's NSP. Not addressed. 4. Explain in detail how the CQI will adopt outcomes, indicators, and practice standards, including outcomes associated with trauma-informed and culturally relevant services. Not addressed. 5. Explain how the facility shall work collaboratively with the Department on the CQI program by being timely and responsive to Department meeting requests, correspondence, and other similar requests by the Department related to CQI. Not addressed. 6. What role will the Board of Directors play in the CQI process? Not addressed. Section says information will be presented to the Board of Directors, no indication of their role. 7. Explain how CQI program will be culturally relevant, trauma-informed, and age and developmentally appropriate. Program Statement 5. Trauma Informed Interventions and Treatment Practices 1. Missing procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma-informed. Still not addressed, how with the facility do this? 2. Missing policies and procedures for collaboration with Child Welfare, Probation, County Mental Health, CFTs, and outside partners to ensure effective and consistent provision of care and services that are trauma-informed. Still not addressed, how with the facility do this? 3. Missing procedures for maintaining consistency with TILPS (when applicable). 7. Development, Implementation, and Modification of Needs and Services Plan 1. Missing procedures to support the reasonable and prudent parent standard, as specified in Section 87067. 2. • Explain how the STRTP will ensure the process of treatment is consistent with the short-and long-term needs and goals for the child, as specified in the child's permanency plan 3. • Include the anticipated duration of treatment 4. • Missing procedures to ensure the child or NMD's needs and services plan is consistent with the case plans including the needs as identified by the qualified individual, as developed by the county placing agency and recommendations by the CFT 8. Planned Activities 1. This section includes activities, but there is no clear plan for the following: · Pre-vocational or vocational counseling. Not addressed, need to add language for this requirement to this section. · Use of the residential environment to assist children/NMDs in the acquisition, testing, and refinement of community living and interpersonal skills. Not addressed, need to add language for this requirement to this section. 2. The written plan for activities does not demonstrate that it allows children/NMDs to participate in age or developmentally appropriate extracurricular, enrichment, cultural, and social activities and ensures that the reasonable and prudent parenting standard as specified in Section 87067 will be applied. Not addressed, need to add language about extracurricular activities to meet this requirement to this section. 3. Please specify if there will be any on-site vocational trainings provided in the facility, including skills taught, goals of the training, hands-on experience received, materials provided, number of hours per day/days per week, and funding. Not addressed, need to add language for this requirement to this section. 4. The development of community support systems for children/NMDs to maximize utilization of non-mental health community services and other resources. 5. Access to computer technology and the internet, consistent with the child's age, maturity,developmental level, court order, and CFT decision. Not addressed. 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Services • Documentation of the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). 16. Personal Rights 1. The procedures do not include the requirement to explain and advise the child and their authorized representative of personal rights at the request of the child, and each time a new right has been added. 2. Additional trainings after hire? Mention that staff also sign personal rights form. 18. Positive Discipline Policies and Procedures 1. Missing procedures for when a youth is subject to positive discipline. Not addressed, need details on when positive discipline will be used. 2. Explain how the positive discipline policies will not violate personal rights. Not addressed, how will this be done? 3. Explain how the positive discipline policies and procedures will be age and developmentally appropriate. Not addressed, how will this be done? 19. Expectations and Consequences for NMDs 1. Need to include a statement that NMD will not be subject to a consequence for refusing to take their psychotropic medication. Not addressed, language needed for this section. 2. Need to include a statement that calls or threats to call law enforcement are not a form of discipline. Not addressed, language needed for this section. 3. Explain how the positive discipline policies will not violate personal rights. Not addressed, how will this be done? 4. Missing section 87072.11(b)(1)-(5). Not addressed 5. Missing procedures for when an NMD is subject to positive discipline. Not addressed, need details on when positive discipline will be used. 6. Types of discipline not permitted. Not addressed 7. Provisions for informing staff, NMDs, and the NMD's authorized representative(s) of expectations and consequences policies and procedures; Not addressed 25. Food and Nutritional Plan/Sample Menus/Schedule 1. Procedures on how all staff will be made aware of any special dietary needs due to allergies, medical conditions, religion etc. 26. Emergency Intervention Plan (Runaway Plan) 1. Missing procedures that include descriptions and details in the written procedures to demonstrate how the licensee will ensure the prevention of personal rights violations. 2. Specify the behaviors that may require the use of emergency intervention. 3. The Manual Restrain Plan is missing sections 87095.22(f)(1)-(7) and procedures for the following: Still not addressed · documenting and maintaining a monthly log of each use of manual restraints, as specified in ILS Section 87095.61(g) 4. There's a brief mention of biannual review but there are no procedures. See section 87095.22(h). 5. There's no mention of the admission agreement. 6. Explain how the Runaway Plan is trauma-informed, culturally relevant, appropriate for the age, size, emotional, behavioral, and developmental level of the child(ren), and account for the particular traumas of specialized populations, including, but not limited to, commercially sexually exploited children. A copy of this report was provided. Mr. Darryl Monteilh stated that corrections would be submitted for review to Licensing Office by February 13, 2026. Corrections made will be highlighted.


summary: Facility Evaluation

raw_content:
Narrative:
On April 16, 2026, at 9: AM Licensing Program Analyst (LPA) Daniel Mena conducted a pre licensing inspection of the facility. At time of inspection LPA met with applicant Darryl Monteilh. The facility was toured inside and out with Mr. Monteilh. The home is a one story four bedroom home with three bathrooms, and two staff offices. Home is divided into two units (building 1 & building 2). Facility has a detached laundry room and mental health office. Bedroom # 1 is furnished with two twin beds and sleeps two clients. Bedroom # 2 is furnished with two twin beds and sleeps two clients. Bedroom # 3 is furnished with one twin bed and sleeps one client. Bedroom # 4 is furnished with one twin bed and sleeps one client. Bedrooms are arranged so that no more than two clients are in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. All hazardous items have been properly made inaccessible. The medications will be stored in a locked cabinet in the staff office. Cleansers/chemicals and sharp knives will be stored and locked. Continues on next page The is a First Aid Kit on the premises. The facility's smoke detectors and carbon monoxide detectors were operable. There are no guns/weapons in the facility. The following required posted items will be made accessible to clients: Grievance Procedures, Personal Rights, and Visitation policies. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There are no pools or other body of water on grounds. There is a creek behind the facility that has been made inaccessible with fencing. The request of License will be forwarded to Licensing Program Manager for final approval once Fire Clearance is provided. Exit interview conducted and a copy of this report was discussed and provided to Applicant, Darryl Monteilh on this date.

visit_type: Prelicensing


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
revealed that C2 was found with a blanket over C2's head. Confidential interviews could not determine in which manner the blanket covered C2's head and how long the blanket had been on C2's head. Confidential interviews revealed that C2 had the blanket removed from C2's head and displayed loud and heavy breathing, but C2 remained asleep and was not showing signs of distress. C2 was monitored by facility staff throughout the day for signs and symptoms of distress or discomfort. Additionally, confidential interviews revealed that C2 did not receive a follow-up medical evaluation because C2 did not show any signs and symptoms of distress or discomfort requiring further medical evaluation. Based on confidential interviews and record review, the allegation that facility staff did not seek timely medical attention for C2 while in care may have occurred; however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was emailed to Program Director, Erika Vasquez for signature. The original signed report will be placed in the facility file.

Investigation Findings:
13On May 17, 2021, at 4: PM, Licensing Program Analyst (LPA) Jesus Cervantes conducted a tele-visit via Microsoft Teams due to COVID-19 with Program Director, Erika Vasquez, to issue the investigative findings of the allegation listed above. On December 28, 2020, Licensing Program Analyst (LPA), Ann Valenzuela, inspected the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), and Staff 5 (S5). LPA attempted interviews with two of two children (C1 & C2), and Staff 6 (S6). During the investigation, LPA reviewed facility records and obtained copies of the following pertinent documents: Special Incident Report, Needs and Service Plan, and Facility Procedure Manual. On December 28, 2020, Community Care Licensing received an allegation that facility staff did not seek timely medical attention for C2 when C2's head was found swaddled in a blanket. Confidential interviews UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes 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 22-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, THE CITY DR., SUITE FACILITY NAME: CRITTENTON SVCS FOR CHILDREN AND FAMILIESFACILITY NUMBER: VISIT DATE: 05/17/2021

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

report_type: Complaint Investigation

met_with: Erika Vasquez

complaint_status: unsubstantiated


raw_content:
Narrative:
On July 01, Community Care Licensing received an allegation that C1 was inappropriately touched by C2. Confidential interviews and documents reviewed revealed that C2 touched C1's genital area. Confidential interviews and documents reviewed revealed that C2 did not touch C1 inappropriately nor did C2 engage in inappropriate acts with C1. Confidential interviews revealed staff members conduct checks of client rooms every 15 minutes and clients are not allowed to sit on each other's beds. Confidential interviews revealed staff members never saw C1 or C2 engaging in inappropriate acts and never allowed sexual activities to go on among residents. Based on confidential interviews and record review, the allegation that that C1 was inappropriately touched by another child (C2) in care may have occurred; however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Erika Vasquez.

Investigation Findings:
13On October 25, 2021, at 1: PM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Program Director, Erika Vasquez, to issue the investigative findings of the allegation listed above. On 07/12/2021, Licensing Program Analyst (LPA) Jesus Cervantes conducted a 10-day/file review visit to Crittenton Services for Children and Families and reviewed clients and staff files. LPA Cervantes obtained the following documents: Complaint Investigation Reports, Facility Profile, Facility Personnel Report Summary and Personnel List. Investigator Lucius Charlemagne with the Community Care Licensing Investigation Branch investigated this complaint. Investigator Charlemagne obtained and reviewed the following documents: Fullerton Police Department report, medical records from Children's Hospital Orange County (CHOC). Investigator Charlemagne interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Child #1 (C1), Child #2 (C2), Riverside County Probation Officer, Los Angeles County Senior Social Worker, Fullerton Police Department Investigative Branch personnel, and Doctors from CHOC. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes 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 22-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, THE CITY DR., SUITE FACILITY NAME: CRITTENTON SVCS FOR CHILDREN AND FAMILIESFACILITY NUMBER: VISIT DATE: 10/25/2021

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

visit_type: Complaint Investigation


facility_name: DANGERFIELD HOME #1

raw_content:
Investigation Findings:
13On 08/13/2021 at 2: PM, Licensing Program Analyst (LPA) Charmetha White arrived at the above location for the purpose of concluding the investigation and deliver findings on the above allegation. LPA spoke with Administrator, Chinyere Paris Ukattah and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Staff said some clients have been attending school virtually and staff denied preventing clients from attending school. Staff said clients are provided 3 meals a day and are issued weekly allowance. Staff denied threatening clients and said staff have not denied any client their approved visit pass. Staff stated clients are treated with dignity and respect, and staff address each client based on the needs of their treatment plan. Client #1 said staff do not treat everyone the same and said staff told him if he did not go to school he could not go to work. Client interviews revealed clients are feed regularly and that they have community passes. Clients said they use the facility WiFi to attend Zoom classes and they receive their allowance. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview completed. A copy of the report was left with Administrator, Chinyere Paris Ukattah. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White 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 2

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

met_with: Administrator - Chinyere Paris Ukattah


raw_content:
Narrative:
Although the allegations may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. Per California Code of Regulations, Title Regulations, Division 6, Chapters 1 & 5 (GROUP HOMES), There are no deficiencies noted or cited. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On 02/03//2022 4: PM (LPA) Licensing Program Analysts Rosslyn Gray arrived at the DANGERFIELD HOME #1 to conclude the investigation on the above allegation/s and to deliver the findings. LPA met with the Direct Care Staff. Based on the interviews and statements obtained during the investigation process, the allegation cannot be corroborated because supporting evidence includes the following: Supporting evidence obtained from the internal Investigation conducted revealed that there is not enough evidence to support the allegations that "Inappropriate form of discipline used with minor in care. Minor was pushed while in care; Minor was threatened while in care" occured. Evidence to support that appropriate consequences were implemented, was provided with support to meet the childs needs; Trauma informed were implemented identifying triggers and understanding the needs of the child that included Crisis interventions implemented by several staff to intervene and deescalate the situaton. In addition the child denied that the allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: DANGERFIELD HOME #1FACILITY NUMBER: VISIT DATE: 02/03/2022

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

met_with: Direct Case Staff


raw_content:
Narrative:
Due to lack of evidence obtained during the investigation, LPA determines that the allegation of Neglect/Lack of Supervision, and Personal Rights are Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left at the Facility Administrator.

Investigation Findings:
13On September 23,2022, at 12:30PM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to DANGERFIELD HOME #1 to conclude the investigation on the above allegation/s and to deliver the findings. LPA met with the Facilty Administrator to conclude the investigation and to deliver the findings. Prior to entering the facility LPA-Gray conducted a Health and safety risk assessment and asked were there any positive COVID-19 cases and or Monkey Pox. During the investigation LPA-Gray interviewed and accounted for all available relevant parties;and gathered pertinent information in reference to the allegations. The Licensee denied the allegations. Based on confidential interviews and review of documentary evidence, there is no evidence or witnesses to support that the facility staff did not supervise minors and that the staff did not seek medical attention for minor. Documentary interviews were congruent that staff provided the proper supervision and crisis intervention to deescalate and separated the alleged victims. There was no evidence of injuries or bruises. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: DANGERFIELD HOME #1FACILITY NUMBER: VISIT DATE: 09/23/2022

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

met_with: Facility Administrator


raw_content:
Narrative:
Due to lack of evidence obtained during the investigation, LPA determined that the allegations of Personal Rights is Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left at the Facility Administrator.

Investigation Findings:
13On September 29,2022, at 9: AM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to DANGERFIELD HOME #1 to conclude the investigation on the above allegation/s and to deliver the findings. LPA met with the Facility Administrator to conclude the investigation and to deliver the findings. During the investigation LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the allegations. The Licensee denied the allegations. Based on confidential interviews and review of documentary evidence, there is no evidence or witnesses to support that the facility terminated placement without notice and that the staff withheld minor's allowance. Document evidence confirm that the facility implemented a transition determination plan prior to termination. Documented evidence and confidential interviews were congruent and confirmed that minor's obtain allowances based on their age range and that the staff provided proper supervision and crisis intervention in effort to prevent the child from going AWOL. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: DANGERFIELD HOME #1FACILITY NUMBER: VISIT DATE: 09/29/2022

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


raw_content:
Investigation Findings:
13On 06/19/25, at 1: PM, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to the above facility to conclude the investigation and to deliver the findings on the above allegation. LPA Andrea and LPM Lakescia met with Facility Manager Patrick Henry. During the investigation, LPA Andrea interviewed all available parties and reviewed LIC500-Personnel Report, Staff daily notes and Needs and Services Plan. It was reported that (1) "Facility staff threatened youth in care". Based on interview statements from staff, there was insufficient evidence to support said allegation. LPA Andrea was able to confirm that an incident occurred in the kitchen involving S1 and C1 but there were conflicting statements regarding S1 threatening C1. In addition, there were no witnesses that the allegation occurred. LPA attempted to obtain information regarding the incident from C1 but client refused to speak to LPA. As a result, this investigation is being closed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore, the allegation is unsubstantiated. Exit interview was completed and copy of the report and appeal rights were discussed and provided to Facility Manager, Patrick Henry. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Andrea Aceves LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Facility Manager-Patrick Henry


summary: Facility Evaluation

raw_content:
Narrative:
On May 27, 2022, at 10: AM, Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to DANGERFIELD HOME #1 for the purpose to conduct the Required Year Inspection. There is a visitor sign in an a COVID-19 questionnaire at the entrance. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. This facility is Licensed to provide care and supervision for six (6) children ages 14-17 years old, Ambulatory only. The facility also provides services to non-minor dependents. The census this day is five (5). The facility acquired The National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF) valid extended through June 30, 2024. The facility current License, Mental Health Certification dated November 25, 2021, and expires November 24, 2022. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. STRTP Overview: The facility is a single-story home located in a residential neighborhood and it is constructed as follows: 4 bedrooms, two (2) full-size bathrooms, living room, kitchen, laundry area, and backyard. Living room: is equipped with 2 sofas, chair, wooden and glass coffee table, mounted TV, and has a non-operable fireplace. There is also a two (2) small desk chairs, printers, small file cabinet and office supplies. Kitchen: is equipped with a wooden table and 6 chairs, a stove/oven that has 5 gas burners, a refrigerator/top freezer, a microwave, and a deep freezer. LPA's observed adequate perishable/nonperishable food supplies clients are provided nutritious snacks between meals. The Sharp knives, disinfectants/cleaning solutions made inaccessible to the children locked in cabinets. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. The food menu and children personal right are posted on the side of the refrigerator in the kitchen. All medications are kept in a locked kitchen cabinet inaccessible to clients. There is a locked cabinet labeled as First Aid with three (3) First Aid kits complete with scissors, tweezers, thermometer, gauzes, antiseptic and a 1st Aid Manual. Dining Area: One large table with six chairs. Laundry area is located outside on the side of the house near the kitchen door. The laundry area is equipped with a washer and dryer unit that was observed to be in good condition. The laundry detergent is made inaccessible to the children and is disputed according to the load of the laundry. Disinfectants and chemicals are locked in cabinets made inaccessible. Office/Therapy room: This is a 4th bedroom; it is located adjacent to the living room and it is utilized as an office/therapy room. The room is equipped with a sofa, desk, chairs, printer, bookshelf, facility binders and office supplies.Staff office: Is equipped office furniture (i.e desk, computers, printers. There is one (1) facility vehicle parked outside inspected to be in good operating condition. Outdoor Area: LPA observed the facility to have adequate indoor and outdoor activity space and materials. The front and backyards were inspected and found to be clean and free of debris and observable hazards. LPA observed the hot water heater. LPA observed a staff displayed the utility shut-off valves. Bedroom # 1: Currently occupied by one (1) client, the bedroom is equipped two (2) twin sized beds, comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 2: Currently occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 3: Currently occupied by two (2) clients. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is a locked double door from the inside and outside; bathroom #2 with a walk-in closet and a locked storage room with overflow of supplies. Bathrooms: There are two (2) full-size bathrooms. Bathroom #1 is located along the hallway. Bathroom #2 is located inside of bedroom #3. Both bathrooms were observed to be in good repair and working order. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. The Facility was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Carbon monoxide and smoke detectors are working properly. There are two (2) fire extinguishers and was fully charged. Continued LIC Page 2 of Children will be accorded personal rights. Ombudsperson Grievances and Personal Rights are posted on the wall and a suggestion box mounted on the wall. Clients lounge in the living, therapy office and the back yard. The facility phone is located is the living room, clients make private phones calls in the therapy office. LPA observed the child's Needs and Services plans kept in client's personal file; (filed in an individual binder). Children are accompanied to outside extracurricular activities and social events (concerts, NBA, NFL, NHL game, movie theater, bowling, hiking, swimming etc.) Alternate activities have been implemented. Clients are also accompanied parks and recreational facilities and amusement parks. Staff Records Review: LPA reviewed three (3) staff records stored in individual personnel file/binders provided by S1. LPA ensured to thoroughly review the records of the primary active staff (i.e Program Administrator, Facility Manager; and a Direct Care Staff. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for six (6) clients. LPA confirmed that All staff have required criminal record clearance. DOJ, FBI and Child Abuse Response; which meet qualification. QA Administrator provided evidence of staff training transcripts stored RELIAS Training Program Hours of training for various topics. Clients Records Review: LPA reviewed three (3) clients records. . Staff Interviews: LPA conducted a confidential interview with three (3) on duty staff. Client Interviews: LPA conducted confidential interviews with three (3) of the five (5) clients according to the census willing to be interviewed. There were no deficiencies cited at this time. LPA's concluded the Required Year Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Facility Administrator on 05/27/ PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 9.5, there were no deficiencies observed or cited at the time of the visit. Exit Interview was conducted, and a copy of this report was left at the facility. Continued LIC Page 3 of 3

met_with: ADMINISTRATOR


summary: Facility Evaluation

raw_content:
Narrative:
On June 6, 2024, at 10: AM Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to DANGERFIELD HOME #1 for the purpose to conduct the Annual Random Inspection. LPA conducted a Health and safety risk assessment upon arriving at the facility. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. This facility is Licensed to provide care and supervision for six (6) children ages 7-17 years old, Ambulatory only. The facility also provides services to non-minor dependents. The census this day is six (6). The facility acquired The National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF) valid extended through June 30, 2027. The facility current License, Mental Health Certification dated November 24, 2024, and expires November 24, 2025. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. STRTP Overview: The facility is a single-story home located in a residential neighborhood and it is constructed as follows: 4 bedrooms, two (2) full-size bathrooms, living room, kitchen, laundry area, and backyard. Living room: is equipped with 2 sofas, chair, wooden and glass coffee table, mounted TV, and has a non-operable fireplace. There is also a two (2) small desk chairs, printers, small file cabinet and office supplies. Kitchen: is equipped with a wooden table and 6 chairs, a stove/oven that has 5 gas burners, a refrigerator/top freezer, a microwave, and a deep freezer is located outside. LPA's observed adequate perishable/nonperishable food supplies clients are provided nutritious snacks between meals.The Sharp knives, disinfectants/cleaning solutions made inaccessible to the children locked in cabinets. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. The food menu and children personal right are posted on the side of the refrigerator in the kitchen. All medications are kept in a locked mental health room inaccessible to clients. There is a locked cabinet labeled as First Aid with three(3) First Aid kits complete with scissors, tweezers, thermometer, gauzes, antiseptic and a 1st Aid Manual; 1 is located in the facility vehicle. Dining Area: One large table with six chairs. Laundry area is located inside in the kitchen area. The laundry area is equipped with a washer and dryer unit that was observed to be in good condition. The laundry detergent is made inaccessible to the children and is distributed according to the load of the laundry. Disinfectants and chemicals are locked in cabinets made inaccessible. Office/Therapy room: located adjacent to the living room and it is utilized as an office/therapy room. The room is equipped with a two seater sofa, desk, chairs, printer, bookshelf, facility binders and office supplies. Staff office: Is equipped office furniture (i.e desk, computers, printers. There is one (1) facility vehicle parked outside inspected to be in good operating condition. Outdoor Area: LPA observed the facility to have adequate indoor and outdoor activity space amenities. punching bag, weight lifting unit, barbecue grill, lemon tree, and other outdoor plants. The front and backyards were inspected and found to be clean and free of debris and observable hazards. LPA observed the hot water heater on the house exit to the kitchen door. LPA observed a staff displayed the utility shut-off valves. Bedroom # 1: Currently occupied by two (2) children, the bedroom is equipped two (2) twin sized beds, comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 2: Currently occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 3: Currently occupied by two (2) clients. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets, and pillows; adequate drawer and one (1) walk in closet. There is a locked double door from the inside and outside; bathroom #2 with a walk-in closet and a locked storage room with overflow of supplies. Bathrooms: There are two (2) full-size bathrooms. Bathroom #1 is located along the hallway. Bathroom #2 is located inside of bedroom #3. Both bathrooms were observed to be in good repair and working order. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Continued LIC Page 2 of The Facility was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Carbon monoxide and smoke detectors are working properly. There are two (2) fire extinguishers and was fully charged mounted on the kitchen wall. Children will be accorded personal rights. Ombudsperson Grievances and Personal Rights are posted on the wall and a suggestion box mounted on the wall. Clients lounge in the living, therapy office and the back yard. The facility phone is located is the living room, clients make private phones calls in the therapy office. LPA observed the child's Needs and Services plans kept in client's personal file; (filed in an individual binder). Children are accompanied to outside extracurricular activities and social events (concerts, NBA, NFL, NHL game, movie theater, bowling, hiking, swimming etc.) Alternate activities have been implemented. Clients are also accompanied parks and recreational facilities and amusement parks. Staff Records Review: LPA reviewed three (3) staff records stored in individual personnel file/binders provided by S1. LPA ensured to thoroughly review the records of the primary active staff (i.e Program Administrator, Facility Manager; and the Rehabilitation Specialist LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for six (6) clients. LPA confirmed that All staff have required criminal record clearance. DOJ, FBI and Child Abuse Response; which meet qualification. QA Administrator provided evidence of staff training transcripts stored RELIAS Training Program Hours of training for various topics. Clients Records Review: LPA reviewed three (3) clients records. . Staff Interviews: LPA conducted a confidential interview with three (3) on duty staff. Client Interviews: LPA did not interview clients due to the two (2) of the six refused and four (4)children being at school at the time of the inspection. There were no deficiencies cited at this time. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 9.5, there were no deficiencies observed or cited at the time of the visit. LPA concluded the Annual/Random Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Administrator/Chinyere Ukattah Continued LIC Page 3 of 3

met_with: Administrator/Chinyere Ukattah