raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced complaint inspection at the above facility on 3/21/2022. The purpose for this inspection is to deliver the findings for the above allegations. Based on interviews conducted with staff and supportive documentation to include but not limit; photos from facility website.The facility is currently not operational and no clients reside there as repairs are being done. during this investigation it was determined that, although there may have been incidents that were unreported to the department, there are no specific incidents, dates, or times that can be tracked or located to know if they did or did not happen. It was also determined that some of the photos on the website were found to be stock photos from the internet, there were two photos with no known source. The facility was not able to provide contact information or a statement from person who created the website. Therefore these allegations are Unsubstantiated. There were no violations of California Code of Regulations, Title 22, Division Six or Interim Licensing Standards cited during this inspection. An exit interview was conducted and a copy of this report will be sent to Shaniz Beza at 1: PM UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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: Shaniz Beza, Executive Director


state: CA

facility_name: PEACOCK ACRES

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Ana Hernandez, TAY Program Manager at 10: AM on 9/13/24. Due to this incident occuring sometime between 2010 and 2012, LPA was unable to find enough evidence to determine if the facility violated any regulations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Ana Hernandez, TAY Program Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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:

report_type: Complaint Investigation

met_with: Ana Hernandez, TAY Program Manager

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
On September 24, 2021, the Department received a complaint alleging clients engaged in sexual interactions by cuddling/spooning with each other and staff did not provide supervision to meet the needs of the clients. Based on confidential interviews and documents reviewed, Peacock Acres did not provide close supervision as his Needs & Services Plan stated and C1 and C2 cuddled/spooned with each other, without staff supervision. C1 has a history of behaviors that Peacock Acres felt needed the additional staff support. Peacock Acres did not follow C1's Needs & Services Plan as required, which led to the inappropriate client interactions. Additional staff support and staff supervision was needed. Based on confidential interviews conducted and documents reviewed, there is a preponderance of evidence that clients engaged in sexual interactions while in care and staff did not provide supervision to meet the needs of the clients. Therefore, the above allegations, are substantiated.

Investigation Findings:
13Licensing Program Analyst (LPA) Monica Pavia conducted a complaint investigation. LPA Joel Segura initiated a complaint investigation with Executive Director, Shaniz Beza with Peacock Acres on, 9/24/21 at 9:30am. Investigations Bureau Investigator (INV) Mariana Lomeli conducted confidential interviews with clients, staff, Monterey County Sheriff's Department, and county social workers. LPA Pavia conducted interviews with staff and reviewed client Needs & Services, client incident reports and staff training. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Monica Pavia 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: 3 of Control Number 26-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. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 11/09/2021

met_with: Andrew Sandoval

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Attendees of the facility: Shaniz Beza- Interim Administrator, Andrew Sandoval- Administrator, Dr. Jill Anderson, Zeana Bey, LMFT Counties: Cynthia Elkins - Santa Clara County, Kristin Lampling, Alana Kapust, and Krista Hopper Pasillas -Marin County CCL: Nelson Martinez - Regional Manager (RM), Helga Wong - Licensing Program Manager (LPM), and Carolyn Flynn - LPM Selena Hood - Licensing Program Analyst (LPA) Discussion: - Current substantiated complaint re inappropriate sexual interaction and supervision in the facility - Monterey Sheriff involvement to relocate the clients - 2 year of compliance history - Compliance plan - Staffing and Training Facility will do the following and submit them by December 31, 2021: -Written Plan on Weekly Meeting with Management and floor staff re clients' Need and Services Plans - Lic 500 current staff schedule with administrator and manager's work hours in the facility - Written Plan working with Monterey County Sheriff Department and Meetings - Written Plan working with Seneca on the Crisis Line - Training and Plan on de-escalation and intervention on client behaviors -Training information with trainer James Freeman RM and LPMs offered Technical Support Services (TSP) to facility if they want it in the future.

report_type: Facility Evaluation


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the offices of the above facility. The purpose of this visit was to conduct the required annual inspection. The facility is currently closed and not accepting clients. LPA met with Shaniz Beza, Executive Director (ED), at the facility's main offices. ED explained that this facility is currently being used as an office space. LPA reviewed a staff file and interviewed one staff member. No deficiencies were cited at this time. LPA conducted an exit interview with Shaniz Beza, Executive Director at 4:15PM.

visit_type: Annual

met_with: Shaniz Beza


summary: Facility Evaluation

raw_content:
Narrative:
On 02/16/2022 at 2:10PM, Licensing Program Analyst (LPA) Selena Hood and LPA Paul Simien conducted an unannounced visit to the above facility to complete the annual inspection. LPAs met with Zeana Bey, Clinical Director and conducted a walk through of the facility. The facility currently has a census of 0. The facility is currently being used as an office until the facility begins to accept clients again. The facility had some nonperishable foods, but will get more food if there is a potential placement. No deficiencies were cited at this time. LPAs conducted an exit interview with Zeana Bey, Clinical Director at 2:50PM.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
This LIC 809 was created in error under the wrong facility number and location. No signature for this amended report was obtained from the provider. A new LIC 809 and LIC 811 have been created for correct facility number 275200693 located in the open FAS database. Licensing Program Analyst Michelle P. Kyane conducted a case management inspection on April 26, 2022 at 11:39 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, 8 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 3 out of Direct Care Staff and 2 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, April 26, 2022). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Michelle P. Kyane observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Zeana Bey, Clinical Supervisor

met_with: Zeana Bey


summary: Facility Evaluation

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Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joel Segura on 07/14/2021 at 10am. During the inspection LPA Segura met with administrator Andrew Sandoval and Medical Assistant Heydy Hernandez. The facility was inspected inside and out. In placement at this time there are four youth; two of which are taking psychotropic medication LPA Segura began by reviewing the two files for the youth who are taking psychotropic medication at around 10am. During the review LPA Segura observed that neither of the two clients had Assessment Needs and Services Plans signed by the authorized representative. Note however, that one client has been in placement less than 30 days therefore the facility is not required to have that on the file yet. LPA Segura reviewed 2 children's records on site at the facility at 10am. LPA reviewed 3 personnel files on site at 12:00pm LPA Segura interviewed 3 staff on site at around 11am. LPA did not interview any client's during todays inspection. The two youth were asked to participate but refused. LPA explained the purpose of the inspection and the youth still refused to participate. Continued on 809c At around 2pm LPA Segura and Medical Assistant Heydy Hernandez conducted a medication count for two clients. The medication count resulted in C1's (Client 1; Medication 3, see confidential names list LIC 811 dated 07/14/2021) M3 having one extra pill. A count of C2's medication also resulted in an extra pill for M4. The review of the centrally stored logs and PMARs revealed the following: The facility is not logging medication received from a prior placement (only filled by the facility) The facility is future dating medication start date (anticipated start date) not actual start date. This practice may not account for medication refusals. Staff are not indicating on the PMAR when medication is refused; only leaving space blank not noting required refusal information. Per Title Regulations, deficiencies were cited during this inspection. Exit interview conducted, appeal rights discussed and a copy of the report was left at the facility.


facility_name: PEACOCK ACRES GROUP HOMES INC.

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
S1 stated there were no other staff in the immediate area when C1 began to hit S1. S1 indicated that he was attempting to block C1 from hitting him and eventually made it out to the living room where other staff were present and intervened. Staff S3 and S2 intervened and escorted the client to the couch. Interview with former staff S3 on 09/08/21 at 1:45 pm, revealed that C1 had sat down on the couch and appeared to have calmed down. S3 indicated that C1 stood up, still appearing to be calm and then suddenly ran into the kitchen where S1 was attempting to keep distance from C1. S3 indicated that all she witnessed was S1 attempting to deflect C1 from hitting him and pushed C1 away in a further attempt to stop the attack. S3 indicated that again her and S2 escorted the client outside to try and calm him down. S3 indicated that she did not observe any injuries on C1; but did hear C1 say "how could a grown man do that to a little boy". S3 indicated she did not know what C1 was referring to, and assumed it was S1 attempting to push client away. S3 indicated that she did not hear S1 making any inappropriate statements to C1. An interview was conducted with S2 on 08/20/21 at approximately 10:15am. The interview with S2 revealed that C1 was trying to punch and hit S1. S2 stated he did not see S1 hit, handle in a rough manner or hear S1 state anything inappropriate to C1. S2 indicated that C1 did have a negative opinion of S1. A review of the CPS report made regarding this incident did contain a statement from C1 indicated that S1 had hit C1 and had made inappropriate comments toward C1. C1 was taken into custody by juvenile hall and had run away various times since removal from the facility. A review of county welfare database indicates that as of 06/25/ C1 has been missing therefore no interview was conducted. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that C1 was hit, handled in a rough manner or inappropriate comments were made; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed with Nate Garner. No deficiencies were cited. Exit interview conducted and a copy of the report was left with Nate Garner.

Investigation Findings:
13Licensing Program Analyst (LPA) Joel Segura conducted a follow-up complaint investigation to the STRTP (Short Term Residential Therapeutic Program) and met with the facility manager Nate Garner. The purpose of the inspection was to deliver the findings for the above complaint allegations. On 03/18/21 the department received an anonymous complaint alleging that staff S1 had hit, handled in a rough manner and made inappropriate comments to C1 (Child 1, Staff 1, see confidential names list dated 09/14/2021). An interview was conducted with S1 on 04/07/21 at approximately 3pm. S1 indicated that C1 had a behavior incident due to being denied a late evening outing to a store. S1 denied having hit the youth, handling in a rough manner or making any inappropriate comments to C1. S1 indicated the youth was highly agitated and he had encountered the youth in the darkened hallway outside of the staff office. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 09/14/2021

met_with: Nate Garner


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

raw_content:
Narrative:
On this date LPA used their state issued iPhone to take pictures of the grounds at the facility. Pictures consisted of the linoleum near resident bedrooms in need of mopping and sweeping, stained carpets, power outlets missing face plates, missing floor board, visible patches, a small section of the homes siding appeared to have been torn off, cabinets in need of wiping from hand grease, kitchen cabinets with stuck on food particles and spills, and patches that seem to have been damaged again. During the 03/24 inspection, LPA observed that the facility had installed new windows to replace the previously broken ones. Note that although patches are not visually pleasing, they are not an immediate health and safety risk to clients in care and are fixes to damaged walls. LPA Segura interviewed staff S4 on 04/07/21 at 4:15pm, S5 on 08/25/21 at 10:15am, S6 on 08/20/21 at 10am, S7 on 09/01 at 4:15pm, S8 and S2 on 09/17 at 11:00am. See confidential names list LIC 811 dated 09/21/21. LPA Segura obtained staff training records at the facility on 08/25/2021 at approximately 10am. Five staff training documents were reviewed for new hire training. LPA Segura observed that all five staff had evidence that they were trained in accordance with the facilities training plan including Non violent Crisis Intervention and Emergency Intervention Plan. Interviews conducted with S5, S7 and S8 revealed that they had been trained and participate in annual refresher courses. Trainer S7 stated that he conducts regular training to for staff specifically for the nonviolent crisis interventions, other trainings are conducted by the facility manager or self-paced online training by outside providers. The interview with S7 revealed that the runaway training is not part of the Nonviolent Crisis Intervention (NCI) and Emergency Intervention Plan training. S7 stated that the NCI training only touches on runaways when a hold is necessary not prevention. S7 indicated that due to personal rights the facility mostly tries to talk children out of running away and only ever conduct a hold on a child if they are being a danger to themselves or others such as attempting to run into traffic. Continued on 9099C Interviews conducted with staff revealed that staff felt as if they could not do anything to prevent a child from running away; however, did admit that they attempt to talk children out of running away by following them when they attempt to walk away and conduct bed checks overnight to ensure they are still in bed. Staff also report calling non-emergency number for the Monterey Sheriff's office to report a missing child. A review of the facility Program Statement revealed that although the facility does have a Runaway Plan, there is no indication that facility staff are trained in the plan. LPA Segura reviewed at hire training list and new hire training checklists for five staff. None of the documents showed that the facility is training staff on the runaway plan. An interview conducted with S8 confirmed that although staff knows some of the steps of the runaway plan, they had not seen the plan before LPA showed them a copy on 09/17. A brief review was conducted with administrator Andrew Sandoval of the facility training documents and confirmed that the Runaway Plan is not listed on any of the checklists or training materials. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility was in need of repair and deep cleaning and staff were not trained in the agency Runaway Plan. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. During todays inspection LPA Segura was given a tour of the facility ground and observed all windows have been repaired, floors cleaned and swept, carpets cleaned and siding of the home repaired and painted. Deficiencies were cleared as of todays inspection. Exit interview conducted and a copy of the report was left Andrew Sandoval

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On March 11, 2021, The department received a complaint regarding the cleanliness, good repair of the facility and untrained staff. Based physical evidence, observed on March 16, 2021 and March 24, 2021 it was determined that the facility was in disrepair and in need of deep cleaning. On 03/16/2021 at 3:30pm LPA Segura was given a virtual tour of the home by facility manager Nate Garner. A tour of the home revealed that the facility had several broken windows that were caused by a resident on the previous Friday 03/12/21; on 03/14/2021 resident had also destroyed several light fixtures which had been repaired by the inspection on 03/14. On March 24, 2021 at 12:00pm, LPA Segura returned to the facility to conduct a facility inspection. Continued on 812C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 09/21/2021

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

Deficiencies:
87065.11: Based on staff interviews and records review the1
2
3
4
5
6
7Plan of Correction due 09/22/21.

title:
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3
4
5
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7(C)(3)(C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated reporter; This requirement is not met as evidences by


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 11: AM on 6/8/22. On 05/17/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 05/17/2022, and Investigations Branch Investigator (IB) Maria Barragan was assigned to interview individuals involved with the allegations and they denied the allegations were true. IB Barragan conducted confidential interviews from 5/24/22-5/25/22. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Shaniz Beza, Excutive Director


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Bathroom floors were dirty and needed to be mopped. One of the bathrooms had a broken cabinet door that needed to be repaired. A light fixture in the hallway was broken. The TV stand was dirty and had a dead flower with lots of pedals on it. LPA took photos of these observations and will document them in a LIC 813. Based on these observations there is a Buildings and Grounds violation. Based on confidential interviews conducted during the initial visit on 5/20/22 the problem has to do with staffing issues. The combination of new employees, low staffing numbers, and loss of a key employee that handled a lot of the cleaning responsibilities has led to the facility not being maintained. The complaint allegations, staff do not properly maintain the facility and facility is in disrepair, are valid because the preponderance of the evidence standard has been met As a result of this visit, there is one title Regulation and General Licensing Standards Buildings and Grounds (a) violation observed. The facility will be cited (see 809-D for details). Appeal rights were discussed and provided to ED. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED whose signature on this form confirm receipt of these documents.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed complaint. LPA met with Shaniz Beza , Executive Director (ED) at 11: AM on 6/8/22. On 5/20/ LPA made an initial visit to open this complaint. During the visit the following was observed: Carpets were stained and trash was on the ground, it doesn't look like it has been vacuumed in a while. Laundry room floor was dirty, and it looks like it hasn't been cleaned/mopped in a while. clients rooms were all messy, clothes and trash were on the floors. One of the client's room had dirty dishes, food that was not properly stored, food stains/possibly throw up on the floor, a broken light fixture, carpet needed to be vacuumed, carpet need to be cleaned, and dresser/drawers that are broken and need repair. Another client's room had a broken door that needed repair. All the client's rooms needed the carpet to be vacuumed and cleaned. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 06/08/2022


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. On 3/1/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 3/1/2022, and Investigations Branch Investigator (IB) Ruben Munoz was assigned to investigate this allegation on 3/2/22. Based on IB Munoz's investigation and confidential interviews conducted 3/9/22-3/14/22. There was not enough evidence to prove the above allegations occurred. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations . Therefore the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. The allegation was investigated by the Investigations Branch (IB). Please refer to LIC 9099 7/29/ CONTROL NUMBER 26-CR-20220301131245 which entails this: On 3/1/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 3/1/2022, and Investigations Branch Investigator (IB) Ruben Munoz was assigned to investigate this allegation on 3/2/22. Based on IB Munoz's investigation and confidential interviews conducted 3/9/22-3/14/22. There was not enough evidence to prove the above allegations occurred. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations . Therefore the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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:


raw_content:
Narrative:
On 1/27/22, the County received a 14-day notice for a client residing at Peacock Acres. A County representative (CR) claimed they were told the reasoning for this is because Peacock Acres did not have enough staff to safely provide supervision for the client. CR said that the facility mentioned an altercation the youth in question had to show this. This led to the allegations that Peacock Acres does not have sufficient staff, does not provide a safe environment, and a youth was involved in an altercation with another youth while in care. RCR felt that the 14-day notice was unjustified because they felt the client in question was making progress and that they should not be given a 14-day notice because of lack of staffing. On 3/3/22 when LPA Simien asked Peacock Acres about the client's issues and why a 14-day notice was issued. Peacock Acres explained, since placement, the client has struggled with several behavioral challenges that the program is unable to effectively address. These challenges have continued to impede Client's ability to make progress towards his treatment goals and have continued to pose a risk to safety of staff and other residents of the program. Included in these challenges are ongoing property destruction, continuing to store and smoke marijuana in the home, verbal threats to kill and/or harm both staff and other residents, theft of Peacock Acres and other resident's property with intention to sell, and, inciting and provoking another resident to become physically assaultive, punching another resident several times, and ongoing harassment of another resident (refusing to let that resident use the kitchen or exit his room), purposely destroying other resident's property and stalking other residents around the home while posturing and yelling threats and homophobic/transphobic slurs, throwing items at other residents resulting in property damage. The client has been unresponsive to lower level interventions instead requiring police intervention, has been unable to commit to maintaining the ongoing safety of the home and other residents, and voiced his ongoing intention to try to harm other residents. His behaviors have resulted in marked increases in the mental health symptoms of other residents, required Peacock Acres to temporarily place residents in another lower level home to ensure their safety, and have prevented clinical staff from implementing therapeutic components of the program (ex: providing group therapy) due to the need for increased staff ratios to help stabilize the client and maintain safety in the home. When LPA Simien mentioned to Peacock Acres the allegation of not having sufficient staff and that CR claimed that they said they didn't have enough staff, they said that they are maintaining proper staff-to-client ratios based on ILS V.4 standards. They also mentioned that the client in question is much larger than the average client and that it would take more than one staff member to subdue and redirect the client in question. They said they could not risk the whole program for one client. At the time of LPA Simien's inspection of Peacock Acres on 2/16/22 they had the proper client-to staff ratio. Based on the review of staff schedules from 1/1/22-1/31/22 it showed that Peacock Acres did have the proper client-to-staff ratio, although there is no way LPA Simien can confirm staff worked those shifts. CR said that because Peacock Acres does not have enough staff and the altercations the client in question is having, Peacock Acres does not provide a safe environment. When LPA Simien brought up the allegation that the facility does not provide a safe environment, staff responded by saying they felt they provide a safe environment for clients. They mentioned that some of the clients (including the client in question) behaviors and actions create an unsafe environment. Based on confidential interviews LPA conducted with clients on 2/26/22 clients felt that Peacock acres provided a safe environment and only other clients make them feel unsafe. The clients LPA Simien interviewed mentioned the client in question as creating an unsafe environment. LPA Simien asked clients "Has there been any time you have felt or observed yourself, staff, or other kids being in danger at Peacock?". They responded, only when the client in question gets upset, this individual tends to physically attack people. They also mentioned that the client in question bullies and attacks them and because of this they do not like the client in question. When LPA Simien brought up the allegation that a youth was involved in an altercation with another youth while in care, staff responded that although altercations happen between clients, they respond to them within CCL regulations. They also mention that the client in question is usually the aggressor in these altercations with other clients. Staff pointed out an incident that occurred on 2/5/22 where the client in question attacked another client in which they had to call law inforcment and the client in question was booked in juvenile hall. On 2/16/ LPA Simien asked clients, "do you feel like there are enough staff to stop physical altercations?". The clients' responses were mixed. They responded, "yes, staff put a stop to bullying" and "kind of, staff attempts to stop altercations." Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations . Therefore, the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM).

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. During the investigation, LPA Simien conducted confidential interviews. They were conducted on 2/26/22, 3/3/22, and 7/7/22. LPA Simien reviewed and obtained copies of client files, needs and service plans, treatment plan, safety plan for clients, a copy of the staff schedule from 1/1/22-1/31/22, current phone list, graveyard time punch log (staff check in every 30 minutes) from 1/1/22-1/31/22, sleep chart documents for the weeks of 1/1/22 through 1/31/22 for clients, daily mental health progress notes for clients from 1/1/22-1/31/22 and house notes from 1/1/22-1/31/2022, police report numbers and name of responding officers, incident reports for clients for December 2021 and January 2022. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 07/29/2022

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


raw_content:
Narrative:
On 1/27/22, the County received a 14-day notice for a client residing at Peacock Acre and had a preservation CFT meeting with the facility. The facility explained that the reason for the 14-day notice was that they felt the client question could no longer make therapeutic progress in an environment with peers with behavioral issues and that they became a health and safety risk for clients and staff. Peacock Acres suggested that the client would benefit from being placed in an ITFC resource foster home. CFT Facilitator for the County stated that this was not an option for the client unless they could demonstrate sustained progress for 3 months or longer and that ITFC resource foster homes were in short supply and it was unlikely the County would be able to find one. Peacock Acres also suggest maybe placing the client in Texas to be closer to their Mother. The County responded that they legally could not place client in Texas. When LPA Simien talked to a County representative (CR) about the CFT meeting they claimed they were shocked by the 14-day notice and that Peacock Acres said that the client in question was doing well and progressing clinically. When LPA Simien brought this up to Peacock Acres, they acknowledge that the client did well one-on-one with clinical team but regressed with behavioral issues while with other peers with behavioral issues. On 3/3/22 when LPA Simien asked Peacock Acres about the client's issues and why a 14-day notice was issued. Peacock Acres explained, since placement, the client has struggled with several behavioral challenges that the program is unable to effectively address. These challenges have continued to impede Client's ability to make progress towards his treatment goals and have continued to pose a risk to safety of staff and other residents of the program. Included in these challenges are ongoing property destruction, continuing to store and smoke marijuana in the home, verbal threats to kill and/or harm both staff and other residents, theft of Peacock Acres and other resident's property with intention to sell, and, inciting and provoking another resident to become physically assaultive, punching another resident several times, and ongoing harassment of another resident (refusing to let that resident use the kitchen or exit his room), purposely destroying other resident's property and stalking other residents around the home while posturing and yelling threats and homophobic/transphobic slurs, throwing items at other residents resulting in property damage. The client has been unresponsive to lower level interventions instead requiring police intervention, has been unable to commit to maintaining the ongoing safety of the home and other residents, and voiced his ongoing intention to try to harm other residents. His behaviors have resulted in marked increases in the mental health symptoms of other residents, required Peacock Acres to temporarily place residents in another lower level home to ensure their safety, and have prevented clinical staff from implementing therapeutic components of the program (ex: providing group therapy) due to the need for increased staff ratios to help stabilize the client and maintain safety in the home. Peacock Acres said they would try to preserve placement if the County could take back the client while they tried to find more staff to be better equipped to handle the client's behavior issues. The County said that was not possible. Based on conversations with Peacock Acres and CR, there was a miscommunication/misunderstanding regarding the plan of action for the client. Both said that there was an agreement that the client would stay with their mother for two weeks (starting on 2/10/22) while the County found a new placement (with County providing updates). Peacock Acres would attempt to hire more staff to accommodate the client's behavioral issues. The misunderstanding/miscommunication stems from what would happen after the client's stay with their mother. The County said there was an expectation that the client would go back to Peacock Acres if no placement was found. Peacock Acres says there was no agreement to accept back the client after their stay with their mother. On 2/18/22, Peacock Acres received an email from the client's Social Worker stating no placement had been found for client, providing return date for the client and expectations for him to be picked up at the airport. On 2/20/22, Peacock Acres sent an email to the client's Social Worker informing them of the decision not to accept the client back into the facility following return from home visit due to ongoing safety issues presented by doing so. Peacock Acres provided LPA Simien a screen shot of the email with time stamps to confirm that the email was sent to the Social Worker on 2/20/22. Peacock Acres said they didn't get a response back from the client's social worker On 2/22/22, Peacock Acres sent an email with the client's discharge summary to client's Social worker. Peacock Acres provided LPA Simien a screen shot of the email with time stamps to confirm the email was sent on 2/22/22. On 2/23/22, Client and their Social Worker flew to San Jose with the expectation that Peacock Acres were going to pick up them up. The County said that Peacock Acres refused to pick up client because of previous 14-day notice and left the client and Social Worker stranded. Once they realize that Peacock Acres was not going to pick up the client, The County tried calling various staff members of Peacock Acres, but no one answered. This event lead to the allegations: minor was abandoned while in care, wrongful eviction, minor is being deprived of their possessions, staff are not responsive to requests for communication, and facility's phone went unanswered. When LPA Simien mentioned to Peacock Acres the allegation minor was abandoned while in care, they mentioned the emails they sent to the client's Social Worker (mentioned above). They said despite them informing the Social Worker they were not taking back the client and the discharge summary, The County still sent the client and Social Worker to San Jose. When LPA Simien mentioned to Peacock Acres the allegation of wrongful eviction, they said they had a consultation on 2/15 with an Alliance representative regarding the legality of not accepting client back into placement following his two week home visit. Based on this consultation it was determined that the client would not be accepted back following visitation with mother as the County had stopped paying for client's placement after his departure to home visit. The Days to find placement had passed and there was no prior agreement with the County that Peacock Acres would continue placement of client after 14 days. Given client's behaviors prior to leaving on visit and additional events that had occurred in the house, client was increasingly likely to pose ongoing safety risks to the other residents of the home if they returned back. Also, increased staffing beyond required 1:3 staff to client ratio could not be secured to manage this risk. LPA Simien reviewed Peacock Acres Discharge Policy and it states, "Reasons for an unplanned discharge, removal, or transfer include but are not limited to 1. Repeated program violations, 2. Health and safety of other residents is endangered by the child's or youth's continued presence 3. Repeated or prolonged absences from the facility (AWOLs) 4. If it is determined the facility can no longer meet the needs of the child or youth". Peacock Acres determined the client triggered reasons two and four for unplanned discharge, removal, or transfer. On 3/3/ LPA mentioned the allegations facility's phones are not answered, staff are not responsive to requests for communication, and minor is being deprived of their possessions. Peacock Acres said that although they missed the County's calls on 2/23/22 they had eventually contacted them and were working on sending the rest of the client's belongings. On 7/7/ LPA Simien contacted CR regarding Peacock Acres claims regarding the allegations against them. Based on this conversation, CR stated that Riverside County had an arrangement with Peacock Acres to meet the client and Social Worker at the airport and gave no indication they were not going to take back the client. CR said that on 2/23/22 none of the various staff members they attempted to contact answered. LPA Simien encouraged CR to send him any correspondence between them and Peacock Acres. As of 7/29/ CR has only sent LPA a copy of the client's placement history which showed the County paying for the client's placement at Peacock Acres until 3/1/22. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations.Therefore, the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM).

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. During the investigation, LPA Simien conducted confidential interviews. They were interviews on 3/3/22, and 7/7/22. LPA Simien reviewed and obtained copies of the 14-day notice, facility's 14-day notice policy, initial 30-day evaluation, clinical progress reports/logs, needs, service plans, treatment plan, safety plan for client, daily mental health progress notes for client, and the client's social worker information, and all correspondence the facility had with the County starting from when the initial 14-day notice was given (text messages and emails). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 07/29/2022

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
As a result of this visit, there is one Title General Licensing Standards Personnel Requirement (a) violation observed. The facility will be cited (see 809-D for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED whose signature on this form confirm receipt of these documents.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 10: AM on 10/31/22. On 8/3/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 8/3/2022, and Investigations Branch Investigator (IB) Mariana Lomeli was assigned to investigate this allegation on 8/3/22. Based on IB Lomeli's investigation and confidential interviews conducted 8/9/22-10/27/22 there was evidence to prove the above allegations occurred. The preponderance of evidence standard has been met, therefore the above allegations, staff engaged in sexual interactions with client in care and staff made several inappropriate comments to client in care are found to be SUBSTANTIATED. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 10/31/2022

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

met_with: Shaniz Beza , Executive Director


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

raw_content:
Narrative:
clients were allowed to outings and other extracurricular actives. Clients would be able to have outings for four hours and sleepovers for 16 hours. The facility would need to get in contact with client's friend's parents/caretaker before approving sleepovers. During confidential interviews a client stated the facility denied their request to change therapist. The facility provided emails showing that they worked with client's Social Worker to find an alternative therapist. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED. on speaker phone and staff would be present to hear clients conversations. Clients mail was either opened by staff or clients were required to open mail in front of staff members. All three violate a clients right to privacy. Based on records reviewed and interviews, the preponderance of evidence standard has been met, therefore the above listed allegations are found to be SUBSTANTIATED. As a result of this visit, there is one General Licensing Standards Buildings and Grounds violation (80087(b)(1)) and three Interim Licensing Standards Personal Rights violations ((87072(c)(8)), (87072(c)(9)), and (87072(c)(6)(B)). The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided to SPD. Exit interview was conducted and a copy of this report was provided to Steisha Monderoy, SPD whose signature on this form confirm receipt of these documents.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegation. LPA met with Steisha Monderoy, Strategic Project Director (SPD) at 2: PM on 2/16/23. Over the course of the investigation, LPA conducted confidential interviews and reviewed files during this investigation. Based on confidential interviews conducted it was determined that the allegations listed above are substantiated. A witnessed viewed a client slip on water that had leaked from a water cooler. Staff was observed not cleaning up the water after the slip. Individuals stated that the facility would not provide hygiene products in a timely manner and failed to provide requested hygiene products. Clients would often have to use their own funds to resupply hygiene products. Clients' requests for alternative hygiene products were ignored and had to be purchased by clients. Facility had blanketed policy on clients being searched each time they entered and exited the facility. All clients had to take drug tests if one client was suspected of using illicit substances. Clients were not allowed confidential phone calls. Clients would be required to answer SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. This is an official report of an unannounced visit/investigation of a complaint received in our office on 07/27/2022 and conducted by Evaluator Paul Simien PUBLICCOMPLAINT CONTROL NUMBER: 26-CR- FACILITY NAME:PEACOCK ACRES GROUP HOMES INC.FACILITY NUMBER: ADMINISTRATOR:ERNEST HOWARDFACILITY TYPE: ADDRESS: BELMA COURTTELEPHONE: (831) 663- CITY:SALINASSTATE: CAZIP CODE: CAPACITY:6CENSUS: 3DATE: 02/16/ UNANNOUNCEDTIME BEGAN: 02: PM MET WITH:Shaniz beza, Exectuive DirectorTIME COMPLETED:04: PM 9Staff did not seek medical attention to minor while in care. Minors do not have access to food. Staff uses inappropriate discipline. Minor not allowed to attend extracurricular activities. Minor is not allowed to choose own therapist. INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegation. LPA met with Shaniz Beza, Executive Director (ED) at 12: PM on 2/21/ Over the course of the investigation, LPA conducted confidential interviews and reviewed files during this investigation. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. LPA Simien attempted to get in contact with client in question that requested medical attention. As of 2/16/ LPA was unable to reach the client via Parole Officer. Individuals stated that clients did have access to food. LPA determined that the facility used prudent parenting standards locking up snacks due to clients only eating snacks. Clients were not eating dinner or healthy food because they were full from eating too much snacks. Clients could have snacks when requested. A client was put on "restriction" from extracurricular actives due to behavioral issues. Facility stated that the client's social work team agreed to this. As of 2/16/ LPA has been unable to reach the client's Social worker to verify. Pending facility approval, UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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: 2 of Control Number 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 02/16/2023

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

Deficiencies:
80087: Protective devices including but not limited to nonslip material on rugs.

title: Buildings and Grounds (b) (1) All clients shall be protected against hazards within the facility through provision of the following


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Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Steisha Monderoy, Strategic Project Director (SPD) at 1: PM on 8/14/22. The above listed allegations were discovered during complaint investigation 26-CR-20220727133650 (7/27/22). The facility at the time was conducting room searches on all clients randomly regardless if they were suspected of having contraband or not. The preponderance of evidence standard has been met, therefore the above allegations, facility staff searched minors rooms, is found to be SUBSTANTIATED. As a result of this visit, there is one Interim Licensing Standards Personal Rights violation (87072(c)(11)) The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided to SPD. Exit interview was conducted and a copy of this report was provided to Steisha Monderoy, SPD whose signature on this form confirm receipt of these documents. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: 275200693

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


raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Steisha Monderoy, SPD.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegation. LPA met with Steisha Monderoy, Strategic Project Director at 1: PM on 8/14/ Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Peacock Acres provides lockers to clients to safeguard their personal items. Witnesses stated that the client in question did not keep their personal belongings in their locker. It's suspected some of the client's personal belongings were lost or stolen by other clients. Witness stated they never saw staff members treat the client in question disrespectfully. Witness stated that staff did not forget to take the client in question to physical therapy appointments. They said that the client declined to go to the appointments due to them being early in the morning and not wanting to wake up. The facility confiscated the client's iPhone and iPad due to safety concerns. Witness stated that clients were redirected, warned, and disciplined any time bullying occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 08/14/2023

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 12: PM on 8/31/23. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Witness interviewed stated that Peacock acres staff follow it's AWOL policy which is to deter clients from AWOLing, to follow clients that leave the facilty safetly, and then contacting law enforcement. The majority of witnesses stated that staff does not leave clients unsupervised. One witness stated there was an incident where clients were left unspervisied. Another witness involved in that incident denided that clients were left unspuervisied. LPA attempted to contact another witness of this incident but as of 8/31/23 has not gotten a response. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced visit to redeliver findings at 2: PM to the above listed facility. The purpose of the visit was to inform them of the findings for the above listed allegations. LPA met with Residential Manager, Ana Hernandez who assisted with the inspection, and provided an interview. Based on confidential interviews conducted, it was determined that the allegations listed above are unsubstantiated . There were confidential interviews that needed to be conducted, and the LPA was unable to get a callback, and/or complete an interview to be able to substantiate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted at 3: PM, and a copy of this report was provided to Ms. Hernandez. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Ana Hernandez


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Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 12: PM on 11/1/23. On 8/7/23, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 8/7/23, and Investigations Branch Investigator (IB) Elisia Rappe was assigned to investigate this allegation on 8/7/23. Based on IB Lomeli's investigation and confidential interviews conducted 8/23/23-10/4/23 there was evidence to prove the above allegations occurred.The preponderance of evidence standard has been met, therefore the above allegations, Staff did not provided supervision resulting a youth sexaully assulted another youth while in care is found to be SUBSTANTIATED. As a result of this visit, there is one General Licensing Standards violation ( Responsibility for Providing Care and Supervision(a)). The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was emailed to Shaniz Beza, ED SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: 275200693

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 12: PM on 1/5/24. Based on confidential interviews conducted by IB Investigator Elisia Rippe it was determined that the allegations listed above are Unsubstantiated. An individual interviewed gave multiple inconsistent statements to IB Investigator Rippe and Monterey County Deputy Wilhitea regarding the allegation. LPA attempted to contact another individual involved in this incident but as of 1/5/24 has not gotten a response. There were no other witnesses to this incident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Shaniz Beza, ED. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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:


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Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 1: PM on 5/3/24. Based on confidential interviews conducted it was determined that the allegations listed above are Substantiated. Witnesses interviewed stated that the facility gave a client the wrong medication, which was confirmed by an Incident report. Witness interviewed stated that the facility was too cold because the facility didn't have heating. Witness stated that the facility didn't communicate with the client's social worker within an appropriate amount of time. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.As a result of this visit, there is one General Licensing Standards violation ( Furniture, Fixtures, Equipment, and Supplies(a)(1)) and two ILS violations ( Health Related Services(c)) ( Personal Rights(c)(6)).The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was emailed to Shaniz Beza, ED SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: 275200693

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Joel Segura conducted an unannounced inspection at the facility and met with Interim Executive Director Shaniz Beza regarding an incident that occurred on 03/15/2021. The incident indicated that C1 (Client 1, see confidential names list LIC 811 dated 09/30/2021) engaged in property destruction and assault of S1 (Staff 1). LPA Segura investigated the incident and was informed C1 came out of her bedroom window into the courtyard and argued with C2. An interview was conducted with S1 on 04/07/21 at approximately 3pm. S1 stated there were no other staff in the immediate area when C1 began to hit S1. S1 indicated that he was attempting to block C1 from hitting him and eventually made it out to the living room where other staff were present and intervened. Staff S3 and S2 intervened and escorted the client to the couch. Interview with former staff S3 on 09/08/21 at 1:45 pm, revealed that C1 had sat down on the couch and appeared to have calmed down. S3 indicated that C1 stood up, still appearing to be calm and then suddenly ran into the kitchen where S1 was attempting to keep distance from C1. S3 indicated that all she witnessed was S1 attempting to deflect C1 from hitting him and pushed C1 away in a further attempt to stop the attack. S3 indicated that again her and S2 escorted the client outside to try and calm him down. Continued on 809C S1 reported attempting to put C1 in a child hold. Interviews were conducted with S2, S3 and S4. S3 reported that S1 restrained C1 in a bear hug, S3 described S1 attempted to hold C1 from the back. Interview with S4 did not report seeing S1 hold C1 from the back. LPA reviewed Crisis Prevention Institute photographs and it appears a Child Control Position is where a child is held from behind; however, it is not a hugging action. Rather the child is held by their arms crossed in front of them. There was insufficient evidence to conclude that there was an inappropriate hold of C1. LPA Segura concluded there will be no violation per Title Regulations. Exit interview conducted and a copy of the report was provided to the facility.


summary: Facility Evaluation

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Narrative:
On 01/27/2022 at 1:30PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Shaniz Beza, Executive Director, at the office space because a Covid-19 positive staff member had visited the facility itself within the last 10 days. LPA reviewed six staff files, staff schedule, and the employee manual. LPA interviewed three staff members. No deficiencies were cited at this time. LPA conducted an exit interview with Shaniz Beza, Executive Director, at 4:15PM.


summary: Facility Evaluation

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Narrative:
On 02/04/ Licensing Program Analyst (LPA) Paul Simien and LPA Selena Hood conducted an unannounced visit to the above licensed facility's main office. LPAs conducted the inspection in the main office because of a Covid-19 positive client in the above facility. The purpose of this visit was to conduct the required annual inspection. LPAs met with Shaniz Beza, Executive Director, at 10:45AM. LPAs reviewed four staff files, the training log for all staff members, and the disaster plan. LPAs found two filing issues that required Technical Assistance. ILS 87065.1(c)(6)(a) was not met as evidenced by the lack of a current CPR card in one staff member's file. ILS 87065.1(d)(1) was not met as evidenced by the lack of sufficient training hours for one staff member. No further deficiencies were cited at this time. An exit interview was conducted with Shaniz Beza, Executive Director, at 2:00PM whose signature confirms the receipt of this document.


summary: Facility Evaluation

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Narrative:
On 02/16/2022 at 9:30AM, Licensing Program Analysts (LPA) Selena Hood and Paul Simien met Christopher Sakamoto, Youth Support Counselor, at the above facility to conducted the required annual inspection. The current census is four, but there are only two clients currently in the home. LPAs conducted a walk through of the facility. LPAs did not find any deficiencies, all necessary signs are posted and there was a sufficient supply of food. All bathrooms were stocked with soap and cleaning supplies were kept locked. LPAs observed the file room where medication is locked and centrally stored. Youth Support Counselor showed LPAs the centrally stored log and showed that psychotropic medications are logged on a separate page from the rest of the documents. LPAs interviewed the two clients present. LPAs found that both clients are above eighteen, but there are no age exemptions currently for the facility. LPAs will be citing a Technical Violation of ILS 87068.11(f) and require that the facility submit a request for age exemption prior to 2/18/2022. Through file review, LPA created three Technical Assistances based on a violation of CCR 80070(b)(7), ILS 87070(b)(11), and ILS 80069(c). LPAs conducted an exit interview with Christopher Sakamoto, Youth Support Counselor at 1:45PM.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst Michelle P. Kyane conducted a case management inspection on April 26, 2022 at 11:39 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, 8 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 3 out of Direct Care Staff and 2 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, April 26, 2022). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Michelle P. Kyane observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Zeana Bey, Clinical Supervisor. Due to a technical error this report was created and provided via email to Shaniz Beza, Interim Executive Director (shaniz@peacockacres.org) for signature on May 2, 2022


summary: Facility Evaluation

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Narrative:
On 11/22/2022 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield and Selena Hood conducted an announced visit to the facility. The purpose of this visit was to conduct a Psychotropic Medications Inspection. LPA's Belfield and Hood met with staff member Daniela Flores. At the time of the inspection, there were two staff present and one client in the facility. The facility currently has two clients, both clients are prescribed psychotropic medications. LPA reviewed the both clients' files. During the time of this inspection one client was away on a home visit, therefore they could not be interviewed. The second client could not be interviewed as they were not a dependent placement. LPA's interviewed two staff members while in the facility. LPA's reviewed four staff files and the training records. A walk through of the facility was conducted with staff Flores. During the walk-through it was observed by LPA's Belfield and Hood that there were six pieces of wood with small nails sticking out of each one. LPA Hood discussed with staff Torres about removing the wood and staff Torres removed the wood and threw them away. LPA observed facility manager Anamaria Hernandez-Lozano ( who arrived at the facility at 12: PM to assist with the inspection) while conducting the pill count. There were no issues with the pill count. LPA reviewed the centrally stored medication binder and the Psychotropic Medication Administration Records (PMAR). There were no deficiencies cited. An exit interview with Anamaria, Facility Manager, at 2: PM whose signature confirms the receipt of this document.

met_with: Daniel Flores


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with Shaniz Beza, Executive Director (ED) at 12: PM on 11/29/22. During a Psychotropic Medications Inspection on 11/22/ LPA Shikya Belfield conducted confidential interviews. The confidential interviews reveled that a staff member withheld medication from a client for 20 minutes until the client was finally able to convince the staff member to retrieve the medication which was stored in a locked area. Based on this, LPA Simien cited for 80072(a)(4) Personal Rights (See LIC 809-D). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

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Narrative:
Attendees of the facility: Shaniz Beza- Executive Director, Ana Hernadez- Residential Director, Zeana Bey- Clinical Director LMFT Counties: Marni Sandoval, Eva Ortiz - Monterey County, Catherine Johnson, Linda Abdelbaki- Sacramento County, Alain Dominique- Riverside County, Noel Lossing- Santa Barbara County CCL: Helga Wong - Licensing Program Manager (LPM), and Paul Simien- Licensing Program Analyst (LPA) Discussion: - Current substantiated complaint re personal rights violations - Current substantiated complaint re inappropriate sexual relations between staff member and client. - Frequency of Monterey Sheriff involvement with facility - 3 year complaint history - crisis management with Seneca/ Monterey County Sheriff Dept. - Staffing and Training, Staff supervision/care, AWOL policy Facility will do the following and submit them by 4/29/23: -Submit updated Program Statement showing changes made with the program. -Submit written plan on staff training (Prudent Parenting, Crisis Management, Law Enforcement Contact, - Boundaries, ILS V.4, and De-escalation techniques) and how the facility plans to measure staff understanding and implementation of training. -Written plan on how the facility will contact and connect with the community (MHPA & Monterey County Sheriff Dept.) LPM offered Technical Support Services (TSP) to facility if they want it in the future.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Michelle P. Kyane conducted a case management inspection on April, 6 2023 at 12pm 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 4 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, April 06, 2023). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Michelle P. Kyane observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Steisha Monderoy, Director Strategic Program

met_with: Steisha Monderoy


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with Shaniz Beza, Executive Director (ED) at 12: PM on 8/31/23. This case management was opened to discuss an incident report the department received for an incident that occurred on 8/6/23. The incident report stated, "On 8/06/23, C1 was visibly upset and threw a key chain of office keys he stole from the staff office on the floor. C1 also returned a phone, and medication (Melatonin) to staff which he stole from the staff office the previous day 8/5". C1 refers to the client involved. When discussing the incident report ED informed LPA Simien that the keys thrown were not office keys and that the client broke into the staff office by breaking into the office. ED stated that they inspected the set of keys and determined that none of the keys had access to anything related to the facility. ED informed LPA that the phone was a staff members and was locked so the client couldn't access the phone. LPA inquired about how the client was able to access the melatonin. ED responded that she was not sure and that Peacock Acres Residential Manager handled the follow up to the incident. ED agreed to send LPA Simien the follow up documents to review. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with Shaniz Beza, Executive Director (ED) at 12: PM on 11/1/23. This case management was opened to discuss the on going issues with the facility's overnight staff not being able to provide adequate supervision to clients. Starting from 2021, there have been multiple incidents of clients engaging in sexual acts due to lack of supervision. LPA highlighted the importance of resolving this issue as failure to do so could lead to an NCC meeting. LPA asked ED how the facility was planning on dealing with this issue that has repeatedly occurred. ED responded by creating a plan of action (this plan of action is also a POC for a related citation). The plan of action in summary: Hiring two part-time staff for the overnight shift. This will allow the overnight shift to have two staff members from AM to AM. The facility will request future CSEC clients to be placed on 1-on-1 supervision ratio from the placing counties/departments. Facility will implement unannounced audits to ensure overnight staff is completing their duty. Conduct informal meetings with youth documenting their experiences and log their concerns All staff will receive refresher courses in providing attuned supervision. Exit interview was conducted and a copy of this report was emailed to Shaniz Beza.

met_with: Shaniz Beza, Executice Director


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Paul Simien made an announced visit to the above listed facility to conduct a closure inspection. LPA met with Shaniz Beza, Executive Director (ED) at 10: AM on 2/7/24. LPA Simien toured the facility and observed zero clients in care residing at the facility. Facility was cleared of furniture and items. ED surrendered the facility licence to LPA Simien at Peacock Acres main office (different location). As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to ED.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Joel Segura conducted an unannounced inspection at the facility and met with head of Service Andrew Sandoval on June 7, 2021, regarding a Special Incident Report (SIR) that was submitted to Community Care Licensing on February 9, 2021 . Note this report signed on 06/08/2021 due to LPA's battery dying during inspection at the facility. The SIR stated that Staff called law enforcement because there were 15 tablets missing when completing a medication count on 02/07/2021. LPA Segura conducted an interview with the facility manager on 02/10/ Nate Garner regarding the incident. LPA Segura obtained a copy of the police report on 05/20/2021. The police report review revealed that the officer was unable to determine who took the medication as there is multiple staff who have keys and access to the medication. Further the officer indicated that the medication boxes the facility was using at the time, allowed someone to pry the side up and stick their hand in to remove medication. The boxes used were tool utility boxes with a padlock in the middle. The facility since has installed a metal lockbox attached to the wall. The facility completed a staff training on 02/15/2021 and monitored youth for any signs they had taken medication. The interview with Nate revealed that there were room searches done after it was discovered that medication was missing. In addition LPA Segura 06/07/2021 inspected the old medication boxes and confirmed the police officers finding that it is possible to pry open the side and take out items inside. Continued on LIC 809C The investigation consisted of interviews with staff and a review of a police report and in person inspection. Based on the interviews regarding the SIR, the facility did not ensure medication was secure; therefore, the facility is being cited. Appeal Rights were discussed and an exit interview conducted and a copy of the report was provided to Andrew Sandoval via email for a signature.

met_with: Andrew


summary: Facility Evaluation

raw_content:
Narrative:
On 11/22/2022 during an announced Psychotropic Medications Inspection, Licensing Program Analyst (LPA) Shikya Belfield and LPA Selena Hood observed that the facility does not log C1's self administration of M1, M2, and M3. LPAs reviewed Insulin Therapy Daily Log, Centrally Stored Medication binder, client file, and locked insulin storage. Based on observation and confidential discussion, the self-administration of M1, M2, and M3 had. not been documented. M2 and M3 were not documented on the centrally stored medication log. Based on this observation, LPAs cited for 80070(b)(10) Client Records (see LIC809D). LPA Belfield requested the communication log from July 2022-November 2022, facility staff agreed to provide this via email before 12/6/2022. LPAs conducted an exit interview with Ana Maria Hernandez-Lozano, Facility Manager, at 2:15PM. LPAs delivered appeal rights, citation, and plan of correction.

met_with: Ana Maria Hernandez-Lozano


facility_name: PENNACLE FOUNDATION INC

raw_content:
Narrative:
**This is an amended report of the original dated January 19, 2022** adequately supervise minors in care, facility staff allow C2 to smoke cigarettes while in care, and facility does not provide C1 a safe environment. Specifically, it was reported that C2 has been punching C1 in the stomach daily for two weeks and when this is brought to staff's attention, staff don't do anything to stop C2 from doing this. Additionally, it was reported that C2 smokes cigarettes outside the STRTP and staff are aware but do not do anything about this. It was also reported that C2 has threatened to hit C1 more if C1 tells staff that C2 is hitting C1. Per allegation details, a witness does not feel safe in the STRTP. While a witness maintains all of the allegation details are true and occurred as reported, another witness denies all allegations. FM confirmed C2 would intentionally hit C1 on occasion, however, this was not due to lack of supervision, as staff was supervising the clients when this occurred. This was C2's behavior when arrived at the STRTP. Staff redirected C2 and separated C2 from C1 immediately in each incident. Staff confirmed C2 will look for used cigarette butts while on outings and will sneak them into the STRTP to attempt to smoke them. Staff corroborate that they confiscate the cigarette butts when this occurs as C1 knows this is against STRTP rules. Staff corroborate clients are supervised on a continuous basis due to their behaviors and conditions, however, C2 is more independent and does push STRTP boundaries regardless of staff supervision. LPA reviewed C2's needs and service plan and observed there is nothing in the plan stating C2 requires constant supervision. Staff corroborate they have never witnessed C2 threaten C1. Additionally, staff corroborate that C1 has never mentioned the above allegations to staff to be addressed. Also, CSW states C1 has never reported allegations to CSW and CSW has never had concerns with the care being offered at the STRTP. A couple of witnesses confirm they feel safe in the STRTP despite the allegations reported. Based on interviews conducted and information obtained, the allegations that C1 is getting hit by C2 while in care without staff intervening, staff do not adequately supervise minors in care, facility staff allow C2 to smoke cigarettes while in care, and facility does not provide C1 a safe environment, may have occurred, however, they are not supported or proven by evidence. The allegation is, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to Ms. Watishi Turner for original signature. Signed report will be placed in facility file.

Investigation Findings:
13**This is an amended report of the original dated January 19, 2022** On January 19, 2021 at 9: AM, Licensing Program Analyst (LPA) Carmen Escobar conducted an unannounced inspection at the Short Term Residential Therapeutic Program (STRTP) in order to issue the investigative findings for the above allegations. During the investigation, LPA requested documents from client 1 (C1), client 2 (C2), and client 3 (C3's) files including placement agreements, copy of needs and service plans, and special incident reports involving the allegations reported. LPA also obtained a copy of STRTP client roster and staff roster. LPA Escobar conducted interviews with facility manager (FM), staff 1 (S1), C1, client 2 (C2), client 3 (C3), and C1's county social worker (CSW). LPA Escobar completed the initial ten-day inspection at the facility to initiate the complaint on 10/25/21 at 12: PM. No safety concerns were observed. It was alleged that on or around 10/18/21, C1 is getting hit by C2 while in care, staff do not UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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 19-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, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 01/19/2022

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

met_with: Facility Manager-Watishi Turner