summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above, at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley and Licensing Program Manager (LPM) Ann Valenzuela met with Facility Administrator, Kendra Mejia, Jeff Marshall, Abby Handan, Jenny Morey, and Hannah Dunn via Microsoft TEAMS to discuss revisions needed for the Plan of Operations and Program Statement. The following questions were asked and answered: Allowance: The clients do not typically stay at the facility for more than 30 days, so a monthly allowance is not required. LPA suggested a statement with this information be included in the Allowance section. Electronic Documents: Can the organization submit the revisions electronically and LPA confirmed that was fine. Timeline after LPA receives the revisions, it is unknown at this time, however, LPA stated they are making the revisions a priority to review and approve so the Pre-Licensing Inspection could be scheduled. LPA reviewed the revisions and a letter with the revisions listed below was sent earlier in the day to Ms. Mejia. Please adhere to the following guidelines when submitting revisions and/or changes made to the plan of operation and program statement: 1) number all pages, 2) highlight all revisions and/or changes, 3) submit an updated table of contents, noting revision dates, for both the plan of operation and program statement 4) Submit electronically in a binder that is tabbed and divided to the Orange County Office located at The *** City Drive Ste. Orange, CA 92868. The revisions are due by October 28, 2025 before 5:00 pm. Should you have any questions regarding this letter, please contact Licensing Program Analyst Charmaine Linley at (951) 202-1850 or charmaine.linley@dss.ca.gov. Section A Documents: A1. Application (LIC 200):  Please include on the back of the LIC 200 or attach a sheet of any other licensed facilities.  Update applicant name to remove Whittier. A4. Administrative Organization (LIC 309):  Provide a copy of the By-Laws or Operating Agreement and any amendments. A5. Affidavit Regarding Client Cash Resources (LIC 400):  This form was not provided. A6. Surety Bond (LIC 402):  This form was not provided. A7. Monthly Operating Statement (LIC 401):  Please explain why there are no operating costs in the areas listed below: • Household Supplies • Laundry/Dry Cleaning • Personal Hygiene Items • Recreational Activities • Client Transportation • Telephone • Office Supplies • Property Taxes *** A9. Financial Information Release and Verification (LIC 404):  Please provide an updated LIC 404, this can be emailed to LPA Linley. A10. Personnel Report (LIC 500):  Who is designated as the facility manager when the Administrator is not present.  From 7 a.m. to 10 p.m., there shall be one on-duty child care staff person to each ten children, or fraction thereof, present. A11. Personnel Record (LIC 501):  Provide a copy of the LIC 501 for the Applicant/CEO.  Provide a copy of the LIC 501 for the Administrator. A12. Health Screening Report - Facility Personnel (LIC 503):  Provide a copy of the LIC 503 for the Applicant/CEO.  Provide a copy of the LIC 503 for the Administrator. A14. Emergency Disaster Plan (LIC 610C):  This form was not provided.  Provide a signed copy of the LIC 610 that shows two relocation sites away from the facility that are able to accommodate the number of clients/children in the facility.  If the use of the relocation site requires authorization from the agency or person currently in possession. This authorization needs to be verified in writing. A15. Facility Sketch (LIC 999):  This form was not provided.  Sketch must give dimensions of all rooms and designate their use.  Door and window exits must be shown. Indicate exit routes by number as shown on the LIC Emergency Disaster Plan.  A facility sketch is required for all indoor and outdoor space including driveways, fences, storage areas, gardens, recreation areas and other space used by clients/residents. ***  For facilities with multiple buildings on a single site, submit separate sketches for indoor and outdoor space for each building and one sketch showing entire facility and relationship between indoor and outdoor spaces of all buildings, as well as any other use of the building.  Sketch of outdoor space must show dimensions and location of major equipment and swimming pools. Sketch must also identify utility shut-off locations.  If Video cameras will be utilized, provide the following information: (2) The purpose of the video cameras. (3) How children and authorized representatives will be informed of the location of video cameras and their purpose. (4) How licensees will work with placing agencies to address situations in which a child objects to video cameras. (5) How video cameras will be used in a trauma-informed manner. (6) Whether video cameras will be livestreamed only or recorded. (7) If recorded, who will have access to the recordings and how will the recordings be stored and safeguarded. Section B Documents: B1. Partnership Agreement/Articles of Incorporation/Articles of Organization:  This section was not provided. Provide either the Articles of Incorporation, Articles of Organization, or Operating Agreement. B2. Verification of Administrator Qualifications and Certification:  Provide the name and residence and mailing addresses of the facility administrator, a description of the administrator's background and qualifications, and documentation verifying required education and administrator certification.  Provide a copy of the Administrator certificate. B2. Verification of Administrator Qualifications and Certification:  Provide the name and residence and mailing addresses of the facility *** administrator, a description of the administrator's background and qualifications, and documentation verifying required education and administrator certification.  Provide a copy of the Administrator certificate. B3. Verification of Social Worker Qualifications:  This section is missing the documents listed below:  LIC 501: Personnel Record  LIC 503: Health Screening Report  Verification of education and experience, copy of degree and transcripts, and resume  Photo ID  Copy of First Aid Certificate B4. Job Description - each position:  Describe the minimum qualifications for all positions that correspond to licensing requirements. This is to include any special licenses or certificates, or special skills needed to perform the job, cannot just state "meet minimum requirements according to Title 22."  Describe the duties for all positions.  Describe the lines of supervision (This is to include supervision given and to whom, as well as supervision received and from whom). B5. Personnel Policies:  This section was not provided.  Personnel policies are to describe those regulatory requirements commonly associated with personnel practices/policies such as staff coverage, staff qualifications, work schedules and conditions of employment.  The following areas are to be included in this section. • Work hours/shifts for documentation of positions to provide coverage with competent staff. To correspond with staff positions and work days and hours listed on all personnel reports. • Abuse reporting procedures. Documentation must indicate that employees will be informed of their responsibilities to report to the licensing agency as well as to the police and child/adult protective agency. *** • Hiring practices: Including screening of employees for necessary education and experience and informing employees that conditions of their employment include fingerprint clearance, statement of prior criminal convictions, TB clearance, physical examination/health questionnaire, child abuse index check. B6. In Service Training for Staff:  This section was not provided.  Please state specifically who will be conducting the training.  Provide details or a list of what is the New Employee Training and what is the ongoing training.  The training list needs to include the administrator continuing education units. The plan must include how often the training will be given and how the training will be documented for Regulations 80065 and 84065. B7. Program Description:  This section was not provided.  Provide a brief statement of the purpose, goals, and program methods (program philosophy).  Provide the days and hours of operation.  Provide the daily schedule of activities that should state who plans, conducts, and assists clients in participating in these activities.  Provide a one month schedule of planned social, educational, and recreational activities that should state who plans, conducts, and assists clients in participating in these activities.  Provide a description of the basic services.  Provide a description of the optional services provided as listed in the admission agreement.  Describe how the facility will handle medical emergencies if a client becomes ill or injured.  Describe the procedure for handing and assisting client with self-administered medications.  Describe the transportation arrangements and how the facility will ensure that employee do not smoke in the vehicles, whether or clients are in the vehicle.  Provide a description of the community resources and consultants to be used.  Provide the complaint/grievance procedure, where the form will be posted, how the client files a complaint, how the Administrator responds, the timeframe, how the Administrator will communicate with the client, and where the outcome will be stored. *** B8. Rules of Discipline/Personal Rights:  This section was not provided.  Provide a statement that discipline does not include a violation of personal rights.  Describe the types of discipline that will be used and under what conditions each type will be used. The discipline policies shall also address the following, when appropriate: types of discipline not permitted.  Describe the grounds for planned and unplanned/emergency discharges.  Provide a statement that there will be no corporal or unusual punishment used.  Describe how the client will sign the personal rights form at intake and each time a new right has been added.  Provide a copy of the discipline policy and describe how the client and Authorized Representative will sign the form. B9. Admission Policies:  This section was not provided.  Provide the ages of the clients, rates and refund policies, acceptance and retention limitations, pre-admission appraisals, needs and services plans, medical assessments and an admission agreement which contains the typical information a client or his/her authorized representative would need to know prior to entering a facility. A description of the following items must be included in this section. • Persons accepted for care, including age range and compatibility determination process, when necessary. • Intake procedures. • Criteria for assessing appropriateness of placement given an individual client's needs (i.e., interviews, procedures for obtaining and developing the necessary paperwork, etc.) • Needs and services plan. • Client's Rights/Personal Rights. • Medical assessment. • Medical assessment. • Pre-admission appraisal plan. • Emergency information. • Sign-in and sign-out procedures. *** • Immunization requirements. • Physical examination requirements (including TB testing). B10. Sample Menu:  This section was not provided.  Provide a sample menu that will include: • Planned meals and snacks for one week, foods used should be from the four basic food groups. • Portion sizes. • Times meals served. B12. Bacteriological Analysis of Private Water Supply (When Water for Human Consumption is from a Private Source):  This form was not provided. Provide a statement if the water is from public or private water supply. B16. First Aid Card:  Provide a CPR/1st Aid Card for the Administrator and Social Worker. B17. Orientation Certification:  This form was not provided. Provide the Group Home Orientation Certificate. B18. Group Home Program Statement:  Old Version of LIC 9106 was provided. Please provide an updated LIC 9106. Program Statement: Sec # Purpose, Methods and Goals {Ref: CCR: 80022(b)(1); MPP11-402.356(a)}.  Describe how results or outcomes will be measured and how often. Sec # Planned Activities/Use of Community Resources {Ref: CCR 80022(b)(13),84065(e), 84079}.  Identify the staff position responsible for planning, supervising, and conducting activities. ***  Provide an updated plan for indoor and outdoor activities, there are three plans dated 2015.  Provide a list of community resources used by the program specific to Orange County.  Provide an updated Sample Daily Activity Schedule for one week, that includes social, recreational, and educational activities.  Describe the program's planned educational activities and services. The forms provided are for Los Angeles County and dated 2016.  Include: • Special Education; • Use of public and/or private schools; • On grounds school; and • Tutoring, if applicable. Sec. # Special Services/Programs Offered  Describe any special services or programs which will be offered.  If the program provides vocational training, describe: • The skills taught; • Goals of the training program; • Hands-on experience received; • Materials provided; • Number of hours per day/days per week training is provided; and • How training is funded. Sec. # Medical and Dental. (Ref: CCR 80075 (a) (1)-(2).  Describe procedures used to identify and handle medical, dental, and psychiatric emergencies, other than calling the Program Director.  Page 9: Medical, Dental, and Psychiatric Emergencies needs to be updated as Los Angeles County Programs and services are listed.  Identify staff positions responsible for dispensing and destroying medications.  Describe how the facility will obtain a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication. ***  Describe the use of Psychotropic Medication Administration Records (PMAR LIC 622B). A separate log for each psychotropic medication prescribed to the child documenting all the following in Title 22 83070(12).  Provide a statement that medication errors will need to be reported and documented to CCL, according to the timeframes for reporting requirements.  Provide a statement that any medication refusal by a client is considered a "Special Incident" and a report will be sent to Community Care Licensing. Sec. # Transportation (Ref: CCR 80022 (b)(10).  Provide a current list of vehicles the facility uses; the form has vehicles listed from 2016.  Does the facility have a checklist to ensure vehicles are in maintained in safe operating condition, if so, please provide.  Specify how the facility will ensure that only appropriately licensed program staff will transport clients. Sec. # Admission/Intake (Ref: CCR 80022(b)(2) 84068.1 84068.2).  This section is missing.  Describe the facility's program's admission/intake procedures.  Include: • Criteria for evaluating appropriateness of referrals for placement; • Information required to assess referrals for placement; • Timeframe for responding to referring agencies regarding acceptance or rejection of referral; • Staff position responsible for intake; and • Procedures for accepting emergency placements on a time-limited and/or trial basis. Sec. # Needs and Services Plan/Assessment {Ref:CCR 84022(b)(2)}.  Describe the policy regarding participation of the client and their Authorized Representative in developing, updating, and modifying the Needs and Services Plan and obtaining signatures. Sec # Discharge/Removal (Ref: CCR 84068.2, 84068,4).  Provide a copy of the discharge/removal form the client and Authorized Representative will sign. *** Sec. # Visitation Rules and Policies (Ref: CCR 80068 (b)(8) 80068,2 (b)(6), 84072).  Describe when and under what circumstances the clients is permitted to have home visits with parents and/or relatives.  Describe when and under what circumstances the clients is permitted to have overnight visits with parents, relatives, family members, friends. Sec. # House Rules.  Any restrictions of phone calls or monitoring of phone calls will need to be included in the Needs and Services Plan with the reason and the client and Authorized Representative will need to sign.  Provide/describe if clients are allowed to date other clients in placement. Sec. # Discipline Policies [Reference: CCR 80072(a)(3), (7) - (8), 84072, 84072.1]  Describe the types of discipline used, including "probationary period;"  Describe the conditions under which type of discipline will be used. Sec. # Emergency Intervention Plan (Ref: CCR 84800(d), 84801, 84802, 84802.1,84803, 84804 and 84808.  Qualifications of individuals who designed the Emergency Intervention Plan: Provide a copy of Greg Corbin's degree and license and Abby Hamdan's copy of degree and CPI trainer certification.  Please clarify if the facility will be using Pro-Act or CPI as both are mentioned. If using CPI, remove references to Pro-Act.  Admission Agreement must include a written statement regarding the type(s) of emergency interventions the licensee has been approved to use.  Describe all techniques (including manual restraints), when techniques are NOT used, and expected outcomes.  Describe the assessment of underlying or unknown medical or physical condition precluding use of restraints.  Describe the techniques of group and individual behavior management.  Describe the alternative methods of handling aggressive and assaultive behavior.  Describe the techniques for returning the child to planned activity following an emergency intervention. ***  As a reminder, each use of manual restraints must be reported to the Department and the child's authorized representative by telephone no later than the next working day following the incident. Please update this section.  As a reminder, restraints cannot be used as part of a discipline method.  The Emergency Intervention Staff Training Plan is to be included as a component of the emergency intervention plan. The plan must include the following in this section: (1) The type, title, and a brief description of the training that all facility personnel have completed. (2) Training requirements for new personnel. (3) The ongoing training required for existing personnel. (4) Training curriculum as specified in Section 84365(b). (5) Training schedule which identifies when staff training will be offered and provided. (6) The name(s) and qualification(s) of the instructor(s) who will provide the training.  Describe how any report of the use of manual restraints must be reviewed, for accuracy and completeness, and signed by the administrator or administrator's designee no later than the next working day following the incident.  Describe or provide a copy of the monthly log of each use of manual restraints.  Procedures for an internal biannual review of the use of emergency interventions must be developed. Such procedures must include at least the following: (1) A review is to be conducted by the administrator or the administrator's designee. (2) Analysis of patterns/trends of use of emergency interventions in the previous six (6) month period, based on: (A) Review of all records related to the use of emergency interventions for accuracy and completeness. (B) Review of the use, effectiveness and duration of each emergency intervention including, a determination of the effectiveness and appropriateness of the intervention technique used in each situation. (C) Review of the frequency of emergency interventions in the previous six (6) month period. (3) Corrective action plan, if needed. (4) The biannual review and corrective action plan must be submitted to the Department no later than the fifth (5th) day of the month following the review.  Describe the procedure of when and how to involve Law Enforcement. *** Sec. # Runaway Plan (Ref: CCR 84808).  Describe the continuum of interventions used.  Provide more information on "searches," and what does that entail.  Describe how the facility shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child residing in the facility.  Describe how the licensee shall make an initial report to the Department no later than the next business day following each incident and send a written report within seven days.  Describe how within six months of the incident, the licensee shall provide a follow-up report for each incident that includes the following information: (A) The type of incident. (B) Whether the incident involved an alleged violation of any crime, other than an age-based curfew law, by a child residing in the facility. (C) Whether staff, children, or both were involved in the incident. (D) The gender, race, ethnicity, and age of children involved in the incident. (E) The outcome of the incident, if known, including arrests, removals of children from placement, termination or suspension of staff, the filing of a Welfare and Institutions Codes Section 602 petition for the child, or revocation of or changes to the terms of probation. Sec. # Children's Complaint/Grievance Procedures [Reference: CCR 84072.2].  This section is missing.  Describe the procedures by which clients or their Authorized Representatives are informed of their rights and permitted to file complaints.  Describe or provide information on how the clients, Authorized Representatives, and staff receive copies of the written complaint/grievance procedures. Sec. # Handling Children's Funds, Allowances, and Salaries [Reference: CCR 80022(b)(12), 80025, 80026, 84026].  Describe the procedure for issuing allowances, including the amount.  Title 22 84077: Personal Services....... *** (2) Provision of an age-appropriate allowance to all children no less frequently than once per month except: (B) If the child is unable to manage their own money because of age or if the authorized representative determines that the child cannot manage their own money. 1. If the authorized representative considers the child incapable of money management, it must be specified in the needs and services plan. Sec. # Nutrition/Sample Menu  Provide a sample menu for seven days with portion sizes.  Describe the times when meals are served. Sec. # Clothing and Incidentals  Describe the "available clothing for use," given to a client. Sec. # Staff Schedule  This section is missing.  Provide a staff work schedule for each facility site which includes names, classifications, days and hours worked. (You may use the LIC Personnel Report.)  Specify the number of hours the program administrator will be at each facility each week.  Specify the number of facilities for which the administrator is responsible. Sec. # Staff Qualifications  Provide copies of resumes or job applications for all child care workers, social work staff, mental health treatment workers, administrators and consultants. If employees have not started work, provide a letter of acceptance/commitment for the position.  Specify the number of hours the program administrator will be at each facility each week, performing administrative duties. Sec. # Job Descriptions  Job descriptions are dated 03/22/2008, have the job descriptions been updated?  Please provide all updated Orange County job descriptions. *** Sec. #24. Inservice Training for Staff/Administrator  Describe the plan for providing initial and annual training for child care staff.  Include: • Position or person who will do the training and his/her qualifications; • Approximate length of training; • Initial and annual training curricula; and • How special training needs are identified and met  Describe the plan for the facility manager training. Please include the course titles and length of each training.  Describe the 5 hours of the annual training that shall consist of course work from an entity other than the group home such as an accredited educational institution, workshops, seminars, or other direct training provided by a qualified individual, who meets the requirements specified in Section 84065(i)(4)(A)1., who is not affiliated with the group home licensee.  Describe or provide a copy of the child care staff assessment within 7 and 30 days of the completion of the 8-hour training and that it will be stored in the personnel record.  Describe how special training needs are identified and then training met to address.  Describe the training for the Reasonable and Prudent Parent Standard.  Describe the initial training that needs to include: (A) Overview of the client population served by the group home; (B) Facility's program and services, including program philosophy, activities and community resources; (C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated child abuse reporter; (D) Child care workers' job description, including roles and responsibilities; (E) Child care workers' self awareness; (F) Role of other facility personnel in service delivery, including case staffing; and the role and responsibilities of the onsite staff member designated to apply the reasonable and prudent parent standard as specified in Section 84065 (b)(1); (G) Discipline policies and procedures; (H) Disaster response *** (I) Medical emergency response; (J) Teamwork and interpersonal communication among facility personnel and clients and client family members; (K) Teamwork and intra-facility communication; (L) The role of placement workers; (M) Medication procedures, assistance with medication, universal precautions, recognition of early signs of illness and the need for professional assistance, and other health related issues ;including oversight and monitoring of psychotropic medications for children in foster care and related topics specified in Section 16501.4(d) of the Welfare and Institutions Code; (N) Group home children's adjustment to group care; (O) Housekeeping and sanitation principles; principles of nutrition, food preparation and storage and menu planning; (P) California Code of Regulations, Title 22; (Q) Availability of community services and resources; and (R) Recreation activities and resources. (S) A child's rights as specified in Welfare and Institutions Code section 6001.9 and Section 84072, including a child's right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity, and gender expression, mental or physical disability, or HIV status. (T) Instruction on cultural competency and sensitivity relating to sexual orientation, gender identity and gender expression, and best practices for, providing adequate care to lesbian, gay, bisexual and transgender children in out-of-home care. (U) The facility's policies and procedures concerning when and how to involve law enforcement in response to an incident involving a child residing in the facility. (V) A child's right to receive sexual and reproductive health care and information. (W) A child's right to have their sensitive health information kept confidential (X) The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. *** (Y) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, age or developmentally appropriate, trauma informed, and strengths based. (Z) Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery.  Submit a one-month training schedule and the length of each training. Sec. #25. Administration  Provide the following information: • Names, addresses (business and residence) and telephone numbers of all corporate officers or partners as appropriate; • Names of all members of the board of directors; • Names and positions of any paid staff who are board members or related to board members; • A current organizational chart which shows lines of administrative authority; and • Copies of the articles of incorporation and bylaws. Sec. #26. Volunteers.  Provide a statement if the facility will use volunteers. If so, describe how volunteers are utilized, screened and trained. Sec. # Facility Sketch  This form was not provided.  Sketch must give dimensions of all rooms and designate their use.  Door and window exits must be shown. Indicate exit routes by number as shown on the LIC Emergency Disaster Plan.  A facility sketch is required for all indoor and outdoor space including driveways, fences, storage areas, gardens, recreation areas and other space used by clients/residents.  For facilities with multiple buildings on a single site, submit separate sketches for indoor and outdoor space for each building and one sketch showing entire facility and relationship between indoor and outdoor spaces of all buildings, as well as any other use of the building. ***  Sketch of outdoor space must show dimensions and location of major equipment and swimming pools. Sketch must also identify utility shut-off locations.  If Video cameras will be utilized, provide the following information: (2) The purpose of the video cameras. (3) How children and authorized representatives will be informed of the location of video cameras and their purpose. (4) How licensees will work with placing agencies to address situations in which a child objects to video cameras. (5) How video cameras will be used in a trauma-informed manner. (6) Whether video cameras will be livestreamed only or recorded. (7) If recorded, who will have access to the recordings and how will the recordings be stored and safeguarded. An exit interview was conducted and a copy of this report was emailed to Ms. Mejia to obtain an electronic signature. A copy of this report will be placed in the facility application file.


state: CA

facility_name: DISCOVERY-ORANGE

summary: Facility Evaluation

raw_content:
Narrative:
On March 25, 2026, at 9:05 am, Licensing Program Analysts (LPAs) Charmaine Linley and Stefanie Mutialu arrived unannounced at the facility for a Post-Licensing inspection. The facility was inspected inside and out with Chief Executive Officer, Jenny Morey. The facility is located on a cul-de-sac behind a large multi-story medical building. The facility was licensed on December 2, 2025. The group home serves clients between the ages of 11-17 years old, both female and male for a capacity of 60 clients. There are eleven clients at the facility. The facility consists of a single level building with four wings. The first (100 unit) wing is licensed by the Department of Public Health and is not licensed through Community Care Licensing. The facility includes two school rooms, two group session rooms, therapy offices, kitchen prep area, kitchen, two laundry rooms, seven offices, tech room, pump rooms, staff break room, intake room and a total of 37 bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds were clean and free of debris. There is adequate indoor and outdoor activity space. There is outdoor space that includes outdoor activities, including a putting ground, planting garden, cornhole game, and large Jenga game. The Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The facility has an industrial kitchen with one industrial sized refrigerator, one industrial sized freezer, one *** industrial sized oven and stove top. There is a storage room for dry goods and additional food. There is an industrial sized dishwasher and sink system. The dining hall is adjacent to the kitchen and has ample sitting space arranged with five large tables and chairs. The facility has inside activities, such as karaoke, piano, dominoes, and televisions that have streaming services to Netflix and Disney. Medication and the first aid kit are kept locked behind a locked door in the Nurse's office. Medication room has a locking door and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility's smoke detectors are inter-connected with the carbon monoxide detectors and are hardwired. The smoke/carbon monoxide detectors were tested and observed to be in working order. There are no guns or weapons in the facility as stated by Jenny Morey. Disinfectants and cleaning solutions were stored locked in each individual wing in a locked storage closet. Sharp knives were made inaccessible and stored in a locked toolbox in the kitchen. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. Wings has thirteen bedrooms and seven bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. Wings has fourteen bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 105 degrees, which is within regulatory requirements. *** Wing has ten bedrooms with two twin beds in each bedroom, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are a total of six bathrooms on this wing that includes one sink, one toilet, and one bath/shower stall. There are no clients residing on this wing at the time of this inspection. There are a total of four fire extinguishers located in all three wing hallways and one in the kitchen. They were observed to be properly charged and inspected by the fire department. Client files are maintained using the KIPU system which is a portal to store client files and keep all information confidential. LPAs reviewed five out of eleven client files and LPA's were unable to conduct client interviews, due to time constraints. Employee files are stored electronically and LPAs reviewed five out of fifty five staff files. LPAs were unable to conduct staff interviews, due to time constraints. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. LPA's will return to complete the inspection and continue reviewing the client and employee files at a later date. An exit interview was conducted and a copy of this report was provided to Jenny Morey. A copy of this report will be placed in the facility file.

report_type: Facility Evaluation

met_with: Jenny Morey


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 2, 2026, at 12:05 pm, Licensing Program Analysts (LPAs) Charmaine Linley and Stefanie Mutialu arrived unannounced at the facility to continue the Post-Licensing Inspection, which was started on March 27, 2026. The facility is located on a cul-de-sac behind a large multi-story medical building. The facility was licensed on December 2, 2025. The group home serves clients between the ages of 12-17 years old, both female and male for a capacity of 60 clients. There are eleven clients at the facility. LPA's met with Program Director, Kendra Mejia and Chief Executive Officer, Jenny Morey. Client files are maintained using the KIPU system which is a portal to store client files and keep all information confidential. LPAs reviewed five out of eleven client files. LPA's conducted six of eleven client interviews during the inspection (see confidential names list, LIC 811, dated 04/02/2026). Employee files are stored electronically and LPAs reviewed five out of fifty five staff files (see confidential names list, LIC 811, dated 04/02/2026). LPA's conducted three of five staff interviews. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. Based on LPA observation and record review, the facility did not have a client roster that was made available to licensing that contains the information in Sections 80071(a)(1)(A)-(C). The facility is being cited for California Code of Regulations Section 80071(a)(1) Register of Clients (see LIC 809D). *** Based on records review, Client #2, Client #3 and Client #9 did not have needs and services plan within 30 days of admission that lists the information in California Code of Regulations Section 84068.2(b)(1)-(5) and 84068.2(c)1-3. The facility is being cited for California Code of Regulations Section 84268.2(a) Needs and Services Plan (see LIC 809D). Based on record review, Client #2, Client #3 and Client #4 did not have a separate log for each psychotropic medication prescribed to the child documenting....the date of the prescription and the number of refills initially prescribed. The facility is being cited for California Code of Regulations Section 84070(b)(16) Children's Records (see LIC 809D). Based on record review, Client #2, Client #3, Client #4, Client #6, Client #7, Client #8, Client #9, Client #10, Client #11 and Client #12 did not have a record of centrally stored prescription medications which includes the following: the name of the prescribing physician, the date filled, name of the issuing pharmacy, and number of refills for each medication. Based on LPA's observation of counting the medication and record review, Client #2, had two medication's total quantity that did not match what was documented on the medication administration record, Client #3 had one medication's total quantity that did not match what was documented on the medication administration record, Client #4 had four medications total quantity that did not match what was documented on the medication administration record and Client #10 had one medication's total quantity that did not match what was documented on the medication administration record. The facility is being cited for the California Code of Regulations Section 80075(k)(7) Health-Related Services (see LIC 809D). Based on record review, Client #2, Client #3 and Client #9 did not have a written medical assessment prior to or within 30 calendar days following their acceptance. The facility is cited for California Code of Regulations Section 80069(a) Client Medical Assessments (see LIC 809D). Based on observation, the facility has locked individual bathroom doors in all bedrooms and the bathroom in the milieu area per Administrator the clients must ask permission from a staff member to unlock the bathroom door before the clients can use a bathroom. The facility is cited for California Code of Regulations Section 84072(d)(18) Personal rights (see LIC 809D). The facility needs to update their Program Statement, send to LPA Linley for review and approval regarding the locked bathroom and bedroom doors. *** The facility was encouraged to use the Compliance and Regulatory Enforcement (CARE) Tools that are available on the CCL website at cdss.ca.gov for all facilities to use as quality assurance tools and to ensure the information requested in the following forms is made available to CCL at future inspections: LIC Client Roster, LIC Identification and Emergency Information and LIC 622b Psychotropic Medication Administration Record. The facility was asked to provide an updated LIC Personnel Report and updated LIC Designation of Facility Responsibility by April 17, 2026. The facility was reminded to submit an updated LIC Personnel Report at a minimum on a quarterly basis if there are personnel changes. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were provided to Kendra Mejia. A copy of this report will be placed in the facility file.

Deficiencies:
84268.2(a): the name of the prescribing physician, the date filled, name of the issuing pharmacy, and number of refills for each medication. Based on LPA's observation of counting the medication and record review, Client #2, had two medication's total quantity that did not match what was documented on the medication administration record, Client #3 had one medication's total quantity that did not match what was documented on the medication administration record, Client #4 had four medications total quantity that did not match what was documented on the medication administration record and Client #10 had one medication's total quantity that did not match what was documented on the medication administration record.

met_with: Kenra Mejia


facility_name: CENTER FOR DISCOVERY -VISTA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Continuation of LIC 9099... Consistent confidential interviews confirmed that the facility has an outside cleaning and pest control service that is contracted to go out to the facility monthly. During the visit, LPA's observed the facility to be clean and sanitary, the food was labeled properly, and confidential interviews did not indicate that the facility is not kept clean. Confidential interviews confirmed that staff are in charge of labeling the food after the food is purchased and brought back to the facility. Confidential interviews also reported that clients also enjoy helping to label and put the food away and, at times, ask if they can rotate who the helper is with labeling food. Confidential interviews confirmed that insects or pests have not been seen inside the facility and pests have never been an issue in the home. During the inspection, LPA was able to retrieve the invoices for the pest control agency that provides the monthly upkeeping of the facility. Based on confidential interviews and observations, the allegations that staff do not ensure the facility was free from pests and staff are not labelling food properly are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Shaianne Tamaleaa, Mental Health Tech III and a copy of this report and appeal rights were provided.

Investigation Findings:
13On June 18, 2025, Licensing Program Analysts (LPA) Lisa Bernabe and Lucero Jauregui, arrived unannounced to Center for Discovery- Vista and met with Shawana Dorsey, Facility Administrator. During the visit, an inspection of the facility was conducted, and no immediate deficiencies were observed. During the investigation, LPA Bernabe interviewed Staff (S1-S3) and Clients (C1- C6). On June 11, 2025, Community Care Licensing (CCL) received allegations that staff did not ensure facility was free from pests and staff are not labeling food properly. It was reported that the company does not follow food safety protocols, and the food is improperly labeled. It was alleged that the facility is not kept clean and free of pests. Continuation on LIC 9099-C.... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR DISCOVERY -VISTAFACILITY NUMBER: VISIT DATE: 09/23/2025

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On June 03, 2022 at 10: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced inspection at the facility above. LPA met with Program Administrator (P1) Nicole Seibert. The purpose of the inspection is to conduct a required annual inspection. LPA inspected the facility inside and out with facility administrator. All six (C1-C6) ambulatory clients were present at time of inspection. LPA inspected the physical plant, operational requirements, disaster preparedness, emergency intervention plan and reviewed six of six client files (C1-C6) (see confidential name list, LIC811, dated 06/03/2022) and four of four staff files (S1-S4). LPA conducted two of two staff interviews (S1-S2) and three of three client interviews (C1-C3). The client and staff files are maintained online and readily available. Medication is kept inside a locked closet in a locked cabinet and centrally stored in the Administrator office. The hot water was measured 110.0 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. The two story residence facility is set up as follows: The first floor consists of the milieu room, dining room, kitchen, four offices located downstairs used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bath room attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bath room attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. The staff supervision station is located in the upstairs milieu for adequate supervision. Based on interviews and observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted, and this report was reviewed with Program Administrator Nicole Seibert and a copy of this report was provided.

visit_type: Annual

met_with: Nicole Seibert


summary: Facility Evaluation

raw_content:
Narrative:
On May 19, 2023 at 8: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection of the facility. LPA met wit Administrator Nicole Seibert. LPA inspected the facility inside and out with facility administrator. All five (C1-C5) ambulatory clients were present at time of inspection. The facility is a three bedroom four bathroom (for client use) in this two story home. The first floor consists of the milieu room, dining room, kitchen, four staff offices, and a two car garage. Offices are used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The staff supervision station is in the upstairs milieu for adequate supervision. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; five fire extinguisher are properly charged and serviced. The hot water was measured 110.0 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. Continued... Facility has a pool which is appropriately fenced and secured with a mesh fence. The enclosure was measured to be 5 feet with a self-latching gate that swings outward. Per facility staff, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu, Staff Schedule and Emergency Plan. LPA reviewed operational requirements, disaster preparedness, emergency intervention plan and reviewed five of five client files (C1-C5) (see confidential name list, LIC811, dated 05/19/2023) and three of three staff files (S1-S3).The client and staff files are maintained online and readily available. LPA conducted two of two staff interviews (S1-S2) and two of two client interviews (C1,C4). A exit interview was conducted. A copy of the report was discussed and provided along with appeal rights to Nicole Seibert, Administrator.

met_with: Nicole Seibert, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 19, 2024 at 8: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection of the facility. LPA met with Julia Franco, Mental Health Technician and Shawana Dorsey, Facility Manager. LPA inspected the facility inside and out with Mental Health Technician. All six (C1-C6) ambulatory clients were present at time of inspection. The facility is a three bedroom four bathroom (for client use) in this two story home. The first floor consists of the milieu room, dining room, kitchen, four staff offices, and a two car garage. Offices are used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The staff supervision station is in the upstairs milieu for adequate supervision. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; five fire extinguisher are properly charged and serviced. The hot water was measured 114.2 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. Continued... Facility has a pool that is fenced and secured with a mesh fence. The enclosure was measured to be 5 feet with a self-latching gate that swings outward. LPA issued a Technical Violation for pool fence not being stable around the back corner of the pool (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Per facility staff, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu, Staff Schedule and Emergency Plan. LPA reviewed operational requirements, disaster preparedness, emergency intervention plan and reviewed six of six client files (C1-C6) (see confidential name list, LIC811, dated 4/19/2023) and five of five staff files (S1-S5).The client and staff files are maintained online and readily available. LPA conducted two of two staff interviews and two of two client interviews. An exit interview was conducted. A copy of the report was discussed and provided to Shawana Dorsey, Facility Manager

met_with: Shawana Dorsey, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On March 19, 2025 at 9: AM, Licensing Program Analysts (LPA's) Lucero Jauregui and Lisa Bernabe conducted an unannounced inspection of the facility. LPA's met with Julia Franco, Mental Health Technician and Shawana Dorsey, Administrator. LPA's inspected the facility inside and out with Mental Health Technician. All six (C1-C6) ambulatory clients were present at time of inspection. The facility is a three bedroom four bathroom (for client use) in this two story home. The first floor consists of the milieu room, dining room, kitchen, four staff offices, and a two car garage. Offices are used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The staff supervision station is in the upstairs milieu for adequate supervision. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; five fire extinguisher are properly charged and serviced. The hot water was measured in bedroom #1 to be at 129.3, and warning sign posted on bathroom sink All hazardous items have been properly locked and made inaccessible to clients. Continued... Facility has a pool that is fenced and secured with a mesh fence. The enclosure was measured to be 5 feet and LPA's observed a deficiency with the self-latching gate. The facility will be cited for Buildings and Grounds 80087(e)(1) [SEE LIC809D]. Additionally, LPA's issued a Technical Violation for Buildings and Grounds 80087(a). [See Lic9102]. Per facility staff, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu,and Emergency Plan. LPA's reviewed operational requirements, disaster preparedness, emergency intervention plan and reviewed six of six client files (C1-C6) (see confidential name list, LIC811, dated 3/19/25) and five of five staff files (S1-S5). The client and staff files are maintained online and readily available. LPA's observed a deficiency with client records. The facility will be cited for Client Medical Assessments 80069(c1)(1) [SEE LIC 809D]. LPA's conducted two of two staff interviews and two of two client interviews. An exit interview was conducted, plan of corrections with developed with Shawana Dorsey, Administrator. A copy of the report was discussed and appeal rights were provided to Shawana Dorsey, Administrator.

met_with: Shawana Dorsey, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 7, 2025, at 11: AM. Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced Plan of Correction visit at the facility. LPA Jauregui met with Shawana Dorsey, Administrator. The purpose of the visit is to issue an LIC 421FC Civil Penalty Assessment for a deficiency that was cited on April 2, 2025. Wet signatures were obtained during today's visit. A hard copy of the signed LIC 421FC will be accessible in the facility file in the San Diego Regional Office. An exit interview was conducted. A copy of this report, along with copies of the LIC421FC and appeal rights were provided to Shawana Dorsey, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 28, 2025 at 11: AM Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced visit to the facility. The purpose of the f the visit is to follow-up on a Plan of Correction (POC). LPA Jauregui met with Shawana Dorsey, Administrator. LPA conducted a safety inspection of the facility and no deficiencies were observed. LPA observed POC to be completed. An exit interview was conducted and a copy of this signed report was provided to Shawana Dorsey, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On October 05, 2022 at 08: AM Licensing Program Analysts (LPA's) Noubar Yerkatyan & Demetris Teal conducted an unannounced inspection at the above facility for the purpose of conducting an annual/required inspection. LPA's met with above staff. LPA's and staff toured the facility. LPA's obtained and reviewed the following updated documentation: · LIC Personnel and Client Roster · LIC C Emergency Disaster Plan · Board of Directors report and Program Statement · Employee Grievance Policy/ Grievance Procedures · Crisis Prevention Intervention Training's · Emergency Preparedness: Disaster and Mass Casualties Drills · Emergency Evacuation Routes · Facility Monthly Activities Calendar · Emergency Intervention Plan · Complaint Procedures The facility was in full compliance with 7 applicable areas of the Compliance and Regulatory Enforcement (CARE) tools for Children's Residential Licenses. Annual compliance review consisted of the following domains: Physical plant, operations, disaster preparedness plan, emergency intervention, staffing, and client records. Community Care Licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. There are 3 fire extinguishers throughout the facility, all fully charged and all last serviced on 10/04/2022 & 09/15/22. The facility has (7) working telephones that is accessible to clients and staff. All passageways and grounds were free of any obstructions. The medications and cleaning solutions were locked inside the cabinets in separate storage rooms. There were perishable foods enough for 5 days and non-perishable foods enough for client's consumption for more than a week. Each bedroom has two twin beds with clean sheets and linens. There were drawers and closet space in each bedroom for client use. The hot water temperature was tested and was in working order. At the time of this inspection the facility was observed to be clean, safe, and in good repair. Administrator is on site 12 hours a day and on-call 24/7. The facility has a Kia Sedona mini-van used to transport clients. The vehicle has an active insurance policy. The facility maintains an equipment/vehicle safety log that is monitored by the Mental Health Lead Technician. The vehicle is serviced every month or as needed. For this review, one (1) Private placement client was selected for the sample to assess the level of care and services they receive. Additionally, LPA reviewed two (2) staff files for compliance with Title Regulations and Interim Licensing Requirements. LPA also conducted interviews with two staff members and two clients. An exit interview was conducted. LPA provided the facility representative above a signed copy the LIC 809 and LIC 811 reports. There were no deficiencies cited at the time of this inspection.

met_with: Chris Oliano, Mental Health Lead Tech & Karla Carrillo, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced visit to the above facility on 4/28/2023 at 10: AM for the purpose of conducting a required annual inspection. LPA met with Program Director Karla Carrillo. LPA reviewed a copy of an updated Personnel Report (LIC 500), The Register of Facility Clients/Residents listing 6 children and the Emergency Disaster Plan for Children's Residential Facilities. LPA along with the facility staff conducted a tour of the facility inside and outside of the home. There are 6 clients currently residing in the home. The following was observed during the inspection: Physical Plant/Personal Accommodations (Buildings and Grounds) - The facility is a two story home. LPA observed the following on the first floor: Four (4) bedrooms,1 office (for Program Director), 1 dining room, 1 kitchen, 1 storage area for medications and bio hazards, 1 pool, 3 bathrooms (2 for clients 1 for staff), 1 living room, and added storage space / laundry room. On the 2nd story, LPA observed 2 office spaces (For therapist), an entrance to the roof, 1 process group room, 1 bathroom (for staff), and the water heater/broiler. In the living room area on a table is a Facility License and a HIPPA Confidentiality Information pamphlet. LPA observed privacy practices documents. Emergency Disaster Plan, client grievances and Title Personal Rights (LIC 613B) were also posted. The following sleeping arrangements were noted: Bedroom # 1 sleeps 2 clients and has two twin beds, two dressers and closet Bedroom # 2 sleeps 2 clients and has two twin beds, two dressers and closet Bedroom # 3 sleeps 2 clients but only has one child in that room and has two twin beds, two dressers and closet. Bedroom # 4 (VIP Room) sleeps 1 client and has 1 twin beds, 1 dresser and locked closet. . All beds are clean and in good repair. Bedding and sheets were sufficient. Food Service - The facility maintains adequate perishable and non-perishable food supplies; the menu plans for the week and weekly program schedules is located on the refrigerator. The kitchen utensils, glasses and dishes were found to be in good condition. In the laundry room next to the kitchen is a backup refrigerator, locked cleaning supplies and a sharp log to track the number knives being used. Emergency evacuation plans are visually placed near the client's restrooms and near exits. On the second floor, LPA observed an emergency plan booklet and clients rights posted. Additionally, there are two couches used for staff meetings. The Administrator's office and an open office are located upstairs. All windows and doors are operable in the home. LPA observed a properly secured swimming pool and jacuzzi (used as a small pool; as the hot water is turned off for safety) in the backyard enclosed with a five foot fence with a self- latching gate. The front and backyard were inspected and found to be free from hazards. The sliding glass door in the staff area faces the backyard and was operable. The hot water temperature was tested and found to be in the mandated range (degree). All exits were free of hazards and all doors opened freely. There is adequate space for indoor and outdoor activity. Exit signs were posted throughout the facility. Sharp knives, medications, and cleaning supplies are kept locked in areas inaccessible to children. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Interviews: LPA interviewed 3 staff ( The Program Director, and Mental Health Tech 2's) There are currently 14 staff working at the facility. File Review: No file reviews were conducted during this inspection. All adult individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemption. In accordance with California Code of Regulation, Title 22, Division 6. Exit interview was conducted. A copy of the LIC 809, 809C, and LIC 811 was provided to the facility representative. At the time of this inspection there are no deficiencies cited per Title 22 regulations.

met_with: Karla Carrillo - Program Director


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews were conducted with seven individuals, C1, C2, C3, M1, P1, S1, S5 during the period of 07/28/2025 to 09/23/2025. An investigation was conducted regarding the allegation: Staff did not treat minor in care with dignity and respect. Six out of seven confidential interviews conducted were consistent that staff do treat minors in care with dignity and respect. C1, C2, C3, M1, P1, and S1 did not express any concerns related to minors being mistreated or dis-respected by staff. Additionally, documentation reviewed, including mealtime rules, Employee code of conduct, chores list and Needs and Services plans does not report children conducting bathroom chores, mistreating or disrespectful behavior between minors and staff. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation(s) are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Lisa Molbert, Program Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Angelique Hill conducted an unannounced complaint inspection with the above facility on 10/20/2025 at 10:00AM and met with Lisa Molbert, Program Director. The purpose of the inspection was to deliver complaint findings for the allegation of: Staff did not treat minor in care with dignity and respect. On 07/28/2025 at 10:30AM Licensing Program Analyst (LPA), Angelique Hill, arrived unannounced at the facility for the purpose of initiating a complaint investigation related to the above allegations. LPA met with Cassandra Linger, House Manager. LPA conducted an inspection of the facility. During the course of the investigation, the following documents were gathered and reviewed: Client Roster for May - July 2025, Staff Roster from May - July 2025, and work schedule for May - July 2025, Needs and Services Plan for all clients, Safety Plans, House rules, Employee rules and incident Reports for all youth between May - July 2025. No serious concerns noted. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Angelique Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MHFACILITY NUMBER: VISIT DATE: 10/20/2025

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

met_with: Lisa Molbert, Program Director


facility_name: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MH

summary: Facility Evaluation

raw_content:
Narrative:
On June 24, 2022, Licensing Program Analysts (LPAs) Jessica Caplinger and Yuvi Diaz conducted an unannounced inspection to the facility for the purpose of the required 2 year inspection. LPAs met with Rob Thomas, Regional Director, and Armando Orneles, Facility Manager (FM). Walk through was conducted with FM. Administrator (AD), Britney Gay arrived and conducted the remainder of the inspection with LPAs. During the course of this inspection, LPAs observed the facility to be clean, safe and sanitary. Six staff and six clients were present during inspection. Two staff took five clients on an outing shortly after LPAs arrived to facility and returned later in the inspection. Postings observed in the entryway included the facility license, personal rights and accreditations. The facility is equipped with 4 bedrooms for client use and 3.5 bathrooms. Bedroom #1 is a single set up while bedrooms #2-4 are doubles. The home has a large family room inside the entry way to be utilized for visitation, relaxation and phone conversations, and a large dining room on the other side of the entry. The home has a large kitchen which opens to the main family room/group space. Kitchen was observed with a stocked fridge and freezer with adequate food supply and perishables. Menu was observed posted. On the back of the family room is a small separate space that has been designed to be an art therapy studio. Both the family room and art room open up to a large covered patio with outdoor bbq, ping pong table and several sitting areas. Over the counter medications, first aid supplies and a refrigerator for medication that may need cold storage are all locked . There are several cupboards in the bathrooms and hall with an abundance of linens, towels and cleaning supplies. The attached two car garage has an extra refrigerator and storage space. Report continues on LIC 809-C There is a second separate building with a garage and an apartment suite on the second floor that is being utilized for the therapy offices. There are no fire arms or bodies of water. All dangerous objects and chemicals are locked. Facility is well maintained and clean through out, the facility is comfortable and set up to support clients. Fire extinguishers are up to date, carbon monoxide was tested and in working condition, water temperature was on average at 110 degrees throughout the facility, and the first aid kit was stocked. Medication is stored correctly and locked. Sharps are kept locked in the locked office. Staff and client files are kept secured. A review of licensing information system was done on 5/31/22 indicating that all staff associated to the facility had DOJ, FBI and Child Abuse Index Check clearances. The facility currently has six clients, two full time clinicians, six full time staff and two part time staff. LPAs interviewed three clients and two staff. LPAs reviewed three staff and three client files. Review of staff files indicate that staff have current training in CPR, FA, AED, disaster preparedness and meet the educational and medical health requirements. Client files contained copies of personal rights, needs and services plans, medical history and consent form. CARE Tools completed. The following domains were completed: Physical Plant, Operations, Emergency Intervention, Disaster Preparedness, Client Files, and Staffing. No deficiencies were noted at this inspection. Exit interview was conducted with Britney Gay, administrator, and a final copy of this report will be emailed to the facility.

met_with: Britney Gay, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9/8/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection for the purpose of conducting a case management regarding an incident that occurred on 7/24/22. LPA met with Taylor Artley, Therapist, to discuss the incident and obtained documentation of treatment plan and treatment team notes for one youth. LPA conducted a walk through to observe the facility inside and outside. LPA met with Sarah Dunning, Education Liaison, to review the incident and review this report. No deficiencies were noted during this inspection. Exit interview was conducted with Sarah Dunning, Education Liaison, and a final copy of this report was left at the facility.

visit_type: Case Management

met_with: Sarah Dunning; Education Liaison


summary: Facility Evaluation

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Narrative:
On August 16, 2023 at 11: AM Licensing Program Analyst (LPA), Stephannie Verna, arrived unannounced at the facility for the purpose of gathering information related to an incident that was reported to the Department. LPA met with Sarah Dunning, Milieu Manager, (S1) who assisted LPA with the inspection of the facility. LPA Verna gathered information regarding client(s) involved in an incident, and S1 informed LPA that they are not residents at the facility based on a review of the facility's client roster. LPA Verna gathered information regarding their placement location, and confirmed FC1 is not residing the residential facility (C1). LPA conducted an inspection of the facility. No deficiencies were observed during today's inspection. A copy of this report was issued to the facility and an exit interview was conducted with Sarah Dunning, Milieu Manager.

met_with: Sarah Dunning, Milieu Manager


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPAs) Jean Stidman and Janie Davis made an unannounced Annual inspection on 11/3/23 10am During the inspection LPAs met with Diana MacNeill Program Director who assisted with the inspection.LPAs conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection three staff and six clients were present. Number of staff interviewed two Number of clients interviewed two. LPA observed # 4 bedrooms, # 3 bathrooms LPAs inspected and/or reviewed the following: I. Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F 41 degrees Freezer Temperature at or below 0 degrees_-2 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__122.5 degrees_. LPA observed facility staff have hot water warning signs posted; Fire Extinguishers inspected Jan/Feb 2023. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Posted _X__ Board Minutes Reviewed __X__ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __N/A_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed _five Criminal record clearances verified _five_ First Aid Certificate__five__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed five Needs and Services Plan five Centrally Stored Medication and log reviewed five Psychotropic Medication and log reviewed five__Cash Resources__N/A__ Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80069(c)(1) and 80069(c)(4) Client Medical Assessments due to three out of five clients records were missing documentation of the client's ambulatory status and two out of five clients records are missing documentation of the client's examination for communicable tuberculosis and other contagious/infectious diseases. The following items were reviewed for compliance: · Annual fees · Administrator Certificate for: Diana MacNeill Program Director · Emergency Disaster Plan (per H&S Code 1565) · Personnel Roster, Facility Sketch, LIC500 and LIC610C. An exit interview was conducted with Diana MacNeill Program Director and a copy of this report was left with Diana MacNeill Program Director.

met_with: Diana MacNeill Program Director


summary: Facility Evaluation

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Narrative:
On March 21, 2024, Licensing Program Analysts (LPAs) Jean Stidman and Angelique Hill, met with Sara Dunning, Millieu Manager, for the purpose of a case management inspection regarding an incident that occurred on 03/08/2024. LPA's inspected the facility inside and out. A new client arrived during the inspection. LPA's observed five clients on site and four staff. No violations were sited. Exit interview conducted and a copy of the report left with Sara Dunning, Millieu Manager.

met_with: Sara Dunning, Millieu Manager


summary: Facility Evaluation

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Narrative:
On 10/17/24 at 9:40AM Licensing Program Analyst (LPA), Angelique Hill, made an unannounced inspection for the purpose of a case management. LPA met with Diana MacNeill, Program Director, to discuss one child's medication intake. LPA conducted an inspection inside and outside of the facility. LPA requested the following documents for review: Staff Roster, Client Roster, Staff Work Schedule, Medication procedures, training logs for three staff. For one youth, LPA requested: Needs and Services plan, Client Information/Face sheet, medication logs, Identification and Emergency Information, Vital sign history and emails from psychiatrist dated from 10/03/24 and 10/15/24. No citations were issued related to the case management inspection. Further Investigation is needed. A copy of this report was left with Diana MacNeill, Program Director.

met_with: Diana MacNeill, Program Director


summary: Facility Evaluation

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Narrative:
On 10/01/2025 at 09:00AM Licensing Program Analyst (LPA) Angelique Hill arrived unannounced for the purpose of an annual inspection. During the inspection LPA met with Lashiqua Davis, Mental Health Technician III who assisted with the walk-through of the facility. LPA conducted a walk-through of the facility inside and out. Two staff and five youth were present during the inspection. LPA reviewed five staff files and interviewed two staff and two youth clients. LPA inspected and reviewed the following: I. Physical Plant Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible __X___ Refrigerator Nonperishable Foods and fresh perishable foods __X___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_ Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_.Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Laundry Facilities __X___ Bedrooms-required linen and furnishings __X___ Bedroom (required bedding/furniture, furniture in good repair) __X___ No citations were issued related to the annual inspection. Continuation of annual inspection is needed. A copy of this report was left with Lisa Molbert, Program Director (P1).


facility_name: CENTER FOR DISCOVERY, BRENTWOOD II

summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
... oral sex, "fingering" (or digital sex) in the living room while night staff was not looking, and kissing and sexual acts in the laundry room during the day. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Section Responsibility for Providing Care and Supervision. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt. ... the full movie was shown or that residents have felt traumatized/re-traumatized by media at the facility. Additionally, a book on the Wicca faith was read by R1 while in care, but it could not be determined how the youth obtained the book, and staff named as the one who brought it in and approved it denied doing so, stating, as supported by the plan of operation and staff statements, that they are not the one responsible for approving books and would not have done so. The facility removed the book upon authorized representative's request. The facility policy is to have the therapist and/or facility manager approve media (books, movies) available to clients while in care. However, the facility does not keep a list of already approved books or movies nor of movies or media shown to residents. LPA advises, as best practice, that the facility consider maintaining a list of approved films and books and/or maintain a log of films shown on movie nights. Based on the report, the allegation "Facility not meeting minor's educational needs" pertains to resident R1 not completing homework while in treatment. Based on interviews and record review, R1 was not completing all homework assignments, but was completing treatment goals. R1 was allowed to schedule therapy sessions during homework blocks, but 20 hours are provided a week for homework completion. In the remainder of that time, R1 did not complete all homework assignments. Staff statements indicate that, as a short-term treatment program, the program prioritizes patients'/residents' well-being and treatment goals. The program plan of operation provides that completing homework is a house rule, but staff statements indicate that staff cannot force patients to complete homework. Based on the report, the allegation "Facility not following admission agreement" pertains to R1 not receiving 24/7 supervision, as stated in the parent welcome packet provided at admission. Based on interviews and record review, R1 was to receive 24/7 care and be checked at least every 15 minutes. The parent welcome packet provides for four phases with different supervision requirements and privileges. R1 achieved a higher phase and was dropped according to behaviors. Following R1's suicide attempt, supervision was enhanced. Additionally, shift notes indicate staff were attentive to R1, and R1's statements indicate that R1's incidents occurred in part specifically in brief moments when staff turned around and that R1 felt comfortable talking to staff about their treatment goals. The investigation found that there was a lack of supervision resulting in residents engaging in sexual behaviors at the facility, but it could not be determined that a lack of supervision resulted in other violations. Although the allegations may have happened or are valid, based on LPA's observations and interviews with residents, staff, and witnesses, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations are Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt.

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

Deficiencies:
32804: Center for Discovery, Brentwood Iifacility Number: 075650142 Visit Date: 05/05/2022 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32... the full movie was shown or that residents have felt traumatized/re-traumatized by media at the facility.   Additionally, a book on the Wicca faith was read by R1 while in care, but it could not be determined how the youth obtained the book, and staff named as the one who brought it in and approved it denied doing so, stating, as supported by the plan of operation and staff statements, that they are not the one responsible for approving books and would not have done so.

met_with: Program Director Virginia Parish, Assistant Millieu Manager Cecily Smith

title:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., Suite 360 San Bruno, CA 94066 Facility Name


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Administrator Sara Stokes; Lead Tech Carolyn Williams

complaint_status: SUBSTANTIATED


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

met_with: Interim Administrator - Carolyn Williams


summary: Complaint Investigation - Substantiated

investigation_findings: SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


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

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

met_with: Carolyn Williams - Administrator


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Narrative:
However, the facility is being cited for the second allegation in regards to clients cleaning hazardous material as a violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 84072(d)(1) - Personal Rights. Please refer to LIC9909-D for details. At this time, one deficiency has been issued. An exit interview was conducted, appeal rights were provided and discussed, and a copy of this report was given to Lewis Farias, Milieu Manager.

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

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

met_with: Lewis Farias - Milieu Manager


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

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:


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 6/20/25 at 11: AM, Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint inspection at Center for Discovery and spoke with Carolyn Williams, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on LPA's interviews with staff and clients, as well as a review of records, the preponderance of evidence standard has been met. Therefore, the allegation-Staff spoke inappropriately to minor in care-is SUBSTANTIATED. This is a violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 84072(d)(19) - Personal Rights. Please refer to LIC9909-D for details. Since the staff member in the allegation was terminated the Plan of Correction (POC) was cleared immediately. LPA substantiated the same allegation for another complaint on todays date due to there being two different incidents on seperate days. At this time, one deficiency has been issued. An exit interview was conducted, appeal rights were provided and discussed, and a copy of this report was given to Carolyn Williams, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: CENTER FOR DISCOVERY, BRENTWOOD IIFACILITY NUMBER: 075650142

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


facility_name: CENTER FOR DISCOVERY, FRESNO

raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Center for Discovery, Fresno and met with Ciara Armstead. CS conducted confidential interviews and delivered findings of investigation. Based on review of documentation and confidential interviews CS was able to find a preponderance of the evidence that the allegation occurred. This facility is being cited for violation of Title XXII Division Article Chapter 1 section 80075(b)(5)(B) Health Related Services. Copy of this report, citation, and appeal rights provided to facility at conclusion of inspection SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney 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, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/01/2022 and conducted by Evaluator Charles Kinney PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:CENTER FOR DISCOVERY, FRESNOFACILITY NUMBER: ADMINISTRATOR:PRISCILLA LYNCHFACILITY TYPE: ADDRESS: W BLUFF AVETELEPHONE: (559) 412- CITY:FRESNOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 10/04/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Ciara ArmsteadTIME COMPLETED:03: PM 9Staff do not meet the qualifications. Staff yell at the youth. Staff say inappropriate things to the youth in care. Youth are threatened. Youth are not given privacy. INVESTIGATION FINDINGS: 13Complaint Specialist conducted investigation that included review of documentation and confidential interviews. Due to inconsistencies in the information obtained CS was not able to find a preponderance of the evidence the allegations occurred as reported so allegations are deemed unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney 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 24-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, E SHAW AVE FACILITY NAME: CENTER FOR DISCOVERY, FRESNOFACILITY NUMBER: 107207165

met_with: Ciara Armstead


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Daiquiri Boyd and Charles Kinney conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPAs met with Katee Wheaton Milieu Manager and Program Director Roshonda Cureton A tour of the facility was conducted. The Group Home (GH) currently has 5 clients in placement. A file review was conducted, no prior deficiencies were found within the past 12 months. LPAs asked for updated copies of LIC Designation of Administrative Responsibility, LIC Adminstrative Organization, and a copy of the new lease to be presented to Licensing by October 1, 2021. A review of Licensing Information System on September 16, 2021 indicates that all facility staff associated to the GH have DOJ, FBI, and child abuse index check clearances. No citations issued on today's visit. A copy of the report was provided to the GH at conclusion of inspection.

met_with: Katie Wheaton


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Daiquiri Boyd and Charles Kinney conducted an unannounced inspection to the facility for the purpose of conducting an Annual Continuation inspection. LPAs met with Katee Wheaton Milieu Manager and Program Director Roshonda Cureton The Group Home (GH) currently has 6 clients in placement. LPAs asked for updated copies of LIC Designation of Administrative Responsibility, LIC Adminstrative Organization, and a copy of the new lease to be presented to Licensing by email. Interviews of all clients were completed at this visit. A Technical Violation was issued at this visit for one staff due to a CPR expired date of 09/13/21. A copy of the report was provided to the GH at conclusion of inspection.

met_with: Katee Wheaton


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Corina Carrillo conducted a case management inspection 7/13/22 at 10:30am 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,10 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 4 out of Direct Care Staff and 1 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, July 13, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings were reviewed. Based on the analysis of the confidential interviews and youth file review including the safety plans and Needs and Services Plan 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 Carrillo 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 Katee Wheaton.

met_with: Katee Wheaton & Ciara Armstead


summary: Facility Evaluation

raw_content:
Narrative:
On 3/1/22, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced annual inspection. Met at the facility by Facility Manager Ciera Armstead. Additionally present are two mental health techs and a Therapist. A facility physical plant was conducted upon arrival to the facility. 1. Facility Grounds were inspected. 2. Outdoor space observed. No bodies of water observed. 3. Chemicals are generally stored in locked garage cabinets. A few cleaning chemicals were observed under kitchen counter- a technical advisory was issued on this date. 4. Locked and centrally stored medications were observed on this date 5. First aid kit complete with appropriate manual was present upon inspection. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 4 bedrooms, single or double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. At this time, because there are only 3 clients, each client has their own bedroom. 9. Adequate food storage space observed. 2 days of perishable foods and 7 days of non-perishable foods observed 10. Weekly menu observed 11. Dining room observed. Table and seating provided for all clients.. 12.Facility has two full restrooms, both for client use. Water temperature was within the regulatory range. 13. Licensee has a vehicle for use at the facility. insurance and registration are both current. Resident (Client) files reviewed from 1:30-2:30. 3 resident files reviewed. Files were substantially complete. The current Program Director (Administrator) has recently left employment. The facility has a plan in place for a new certified administrator. A Technical Advisory note is provided to the facility on this date to note required documents for a change of Administrator. Facility is directed to work with their assigned Analyst, Charles Kinney (Charles.Kinney@dss.ca.gov). LPA Reviewed 6 (six) personnel records with assistance from HR personnel Accessing online files. As well as reviewed fingerprint/association records for all personnel. Review conducted between 2:30 pm and 3:30 pm. LPA will return at a later time to discuss and issue report regarding personnel records. Information regarding CPI Certifications Requested.

met_with: Ciera Armstead