Document ZLpnza7b5amxoqpOMZ8X5ZrL

STATE OF CALIFORNIA- HEALTH AMD HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 252B NATOMAS PARK DRIVE SACRAMENTO, CA 95633 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Administrator, Gordon Richardson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE; DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/09/2013 10:00 AM 03:30 PM NARRATIVE 1 Complaint Specialist, Susan Sadler met with Administrator, Gordon Richardson to conduct a Case 2 Management Visit. During todays visit, CS reviewed client files and the agency provided a client census and 3 staff schedule. Currently, the census is 10 boys and 2 girls. In addition, the agency provided a copy of the 4 proposed administrator final qualifications for her administrator certification. The agency will submit document 5 to the certifications department for verification. Agency will notify CCL when the certification is approved. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadier TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -- --- DATE: 07/09/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICQQ9 (FAS) - (06/04) Page; 1 of 1 PBS Front Line PRA Request 000075 STATE OF CALIFORNIA - HEALTH AND HUMAN SEHVtCES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLO Regional office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC, PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Administrator, GordonRichardson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/08/2013 01:30 PM 04:00 PM NARRATIVE 1 Complaint Specialist, Susan Sadler met with Administrator, Gordon Richardson to conduct a Case 2 Management Visit, The purpose of the visit was to discuss Agency personnel, review client files and acquire 3 documents. . During the visit, the Agency provided current staff roster and client census which is 13. CS 4 discussed continuous problem regarding incident reports being sent to CCL beyond the seven day 5 requirement. Mr. Richardson stated he has addresses the issue with staff. In addition, Mr. Richardson stated 6 the agency is in the process of working with Yolo County to re-evaiuate the decision to renew the agencies 7 certification. In the event Yolo County does not renew the certification, the Agency is currently working with 8 CCL to change their program form level 14 to Level 12. The agency is communicating with CCL and Yolo 9 County to ensure they follow proper procedures in the level change. The Agency is aiso continuing to work on 10 completing the required training course for their proposed administrator, their plan is to have the staff 11 complete the required course by July 12, 2013. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: d i r i .-- - DATE: 07/08/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. L1CB09 (FAS) - (06/04) Page; 1 of 1 PBS Front Line PRA Request 000076 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 12 TYPE OF VISIT : Case Management - Other UNANNOUNCED MET WITH: Heather Sleuter Facility Manager_________________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/07/2013 09:00 AM 01:00 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 received staff schedules. LPA received facility client census. 3 4 There are currently 12 clients. 10 boys and 2 girls 5 There are currently 3 clients on home pass 6 7 NO AWOL'S 8 9 Pioneer House - 2 clients and 2 staff 10 Trailblazer House - 3 clients and 2 staff 11 Voyager House - 5 clients and 4 staff 12 Sapphire House - 2 clients and 2 staff 13 14 Total: 12 clients/10 staff 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: / DATE: 07/07/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) Page: 1 of i PBS Front Line PRA Request 000077 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 2525 NATOMAS PARK DRIVE ____________________________________________________________________ SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOFLAUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 12 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Heather Sleuter Facility Manager FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/06/2013 11:30 AM 03:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 received staff schedules. LPA received client census. LPA toured the facility houses. 3 4 There are currently 10 boys and 2 girls 5 Out of the 12 clients at the facility 3 clients are on a weekend home pass. 6 There are NO AWOL'S 6 9 Pioneer House - 3 staff and 2 clients 10 Trailblazer House -3 staff and 3 clients 11 Voyager House - 3 staff and 5 clients 12 Sapphire House - 2 staff and 2 clients 13 14 Total: 11 staff/12 clients 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received, FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) - (06/D4) PBS Front Line PRA Request 000078 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 14 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/05/2013 11:15 AM 12:15 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility, LPA 2 received staff schedules, LPA received clients census. 3 4 There are currently fourteen clients at the facility. There are 12 boys and 2 girls 5 6 Pioneer House- 3 clients and 3 staff 7 Traiibiazer House- 3 clients and 3 staff 8 Voyager House- 6 clients and 4 staff 9 Sapphire House- 2 clients and 2 staff 10 11 Total: 14 clients and 12 staff 12 13 NO AWOL'S 14 15 2 clients have graduation dates of 7/12 and 7/S-7/9 16 2 clients are being taken, but no specified dates 17 1 client has a notice, but no specified date > 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) PBS Front Line PRA Request 000079 STATE OF CALIFORNIA" HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA B5833 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 10 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Heather Sleuter-FaciSity Manager FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 {530) 753-0220 95618 07/15/2013 09:40 AM 10:45 AM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 received copies of the staff schedules. LPA received facility client census 3 4 There are currently 10 clients at the facility. 8 boys and 2 girls 5 One out of the 10 clients 1 client is on a home pass 6 NO AWOL'S 7 8 Pioneer House- 2 clients and 3 staff 190 Trailblazer House- 2 clients and 3 staff Voyager House- 4 clients and 4 staff 11 Sapphire House- 2 clients and 2 staff 12 13 Total: 10 clients and 12 staff 14 15 Facility is on Summer School Schedule- Clients attend school half a day. 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME; Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2013 This report must be available at Child Care and Group Home faciiities for public review for 3 years. LIC809 (FAS) - (06/04) PaS6: 1 ! 1 PBS Front Line PRA Request 000080 STATE OF CALIFORNIA - HEALTH AND HUMAN S E R V IE S AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 252S NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/16/2013 09:00 AM 10:00 AM NARRATIVE 1 Licensing Program Analyst Staci Gorubec visited the above facility for the purpose of conducting a case 2 management visit. LPA obtained a client census and staff schedule. There are currently 10 children in 3 placement. There are 13 staff present for the morning shift, 14 staff present for the day shift and 6 overnight 4 staff. 5 6 LPA requested and received proof of staff CPR/First Aid training. 7 8 9 10 11 12 13 14 15 16 17 18 19 2210 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICB09 (FAS) - (06/W) Page: 1 of 1 PBS Front Line PRA Request 000081 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 07/03/2013 and conducted by Evaluator Susan Sadler COMPLAINT CONTROL NUMBER: 23-CR-20130703085745 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Facility Manager, Heather Sleuter________________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/11/2013 01:00 PM 04:00 PM ALLEGATION(S): Reporting Requirements INVESTIGATION FINDINGS: 1 Complaint Specialist, Susan Sadler met with Facility Manager, Heather Sleuter to conduct Complaint Visit. 2 CS reviewed client and staff files. CS advised agency further investigation is required. 3 4 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISORS NAME: Leon Wells TELEPHONE: {916} 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Pa9e: 1 of 2 PBS Front Line PRA Request 000082 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson-Regional Executive Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/29/2013 09:30 AM 01:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 received staff schedules. LPA received client census. LPA toured the facility homes. 3 4 There are currently 14 clients at the facility. Twelve boys and two girls 5 6 NO AWOL'S 7 8 Sapphire House- 2 staff and 2 clients 9 Pioneer House- 3 staff and 3 clients 10 Voyager House- 3 staff and 6 clients 11 Trailblazer House- 2 staff and 3 client's 12 13 Total 10 staff/14 14 15 Out of the 14 clients 3 clients are on home pass 16 17 LPA Hesia received the Awake Night Schedules from May 2012 to May 2013 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916} 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LJC809 (FAS) - (06/04) PBS Front Line PRA Request 000083 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 _____ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 14 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Heather Sleuter-Facillty Manager FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/01/2013 04:07 PM 05:15 PM in NARRATIVE Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA received the staff schedules. LPA received the facility census. 3 4 There are currently fourteen clients at the facility. Twelve boys and two girls. 5 6 7 NO AWOL'S 8 9 Pioneer House - 3 staff and 3 clients 10 Trailblazer House - 3 staff and 3 clients 11 Voyager House - 3 staff and 6 clients 12 Sapphire House - 3 staff and 2 clients 13 14 Total: 12 staff and 14 clients 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 {FAS) - (06/04) PBS Front Line PRA Request 000084 STATE OF CALIFORNIA - HEALTH AND HUMAN SERViCES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95533 FACILITY NAME; FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 14 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/02/2013 04:30 PM 05:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 received staff schedules. LPA received facility client census. LPA toured the facility. LPA interviewed Gordon 3 Richardson. 4 5 There are currently 14 clients in the facility.12 boys and 2 girls 6 7 8 There are NO AWOL'S 9 10 Pioneer House - 3 clients and 3 staff 11 Trailbiazer House - 3 clients and 3 staff 12 Voyager House- 6 clients and 4 staff 13 Sapphire House - 2 clients and 4 staff 14 15 Total 14 clients/14 staff 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2013 i acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATiVE SIGNATURE: DATE: 07/02/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) -{06/04} . Page: 1 gi 1 PBS Front Line PRA Request 000085 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_____________ ____ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY; 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 07/03/2013 11:00 AM 03:30 PM NARRATIVE 1 Complaint Specialist, Susan Sadler met with Gordon Richardson to conducted a Case Management Visit The 2 purpose of the visit was to review client and staff files. During todays visit, staff provided a copy of the staff 3 schedule for the week on July 4th through July 10th and a list of the client placed at the facility. CS advised 4 agency that further investigation is required and will make a return visit to complete file review. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE; (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2013 1acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: r DATE: 07/03/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LJCB09 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000086 STATE OF CAUFORNiA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 13 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson- Regional Executive Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 {530} 753-0220 95618 06/28/2013 03:50 PM 06:00 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 received current facility client census. LPA received current staff schedules. LPA received plan of correction 3 documents. LPA received staff schedules from May 2012 to May 2013. LPA cleared Administrative POC, 4 5 There are currently thirteen clients at the facility. Eleven boys and two girls 6 No clients are on home pass. 7 NO AWOL'S 8 9 Pioneer House- 3 clients and 3 staff 10 Trailblazer House- 3 clients and 3 staff 11 Voyager House - 6 clients and 3 staff 12 Sapphire House has 2 clients and 3 staff 13 14 Total 13 clients/12 clients 15 16 Plan of correction documents received: 17 Replacement mattresses 18 Bedding 19 Thermostat protective cover 20 Clean roll up door 21 Pest Control 22 Food training sign-in sheets and attestations regarding multiple policies 23 Fire clearance, personal rights, fixtures, furniture, equipment and supplies and building and grounds training 24 sign-in sheets and attestations regarding multiple policies 25 Client needs and service plans SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000087 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 0525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33__________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATORlAUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 15 TYPE OF VISIT: Case Management - Deficiencies UNANNOUNCED MET WITH: Gordon Richardson ________________ Regional Executive Director____________________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/27/2013 03:45 PM 06:00 PM NARRATIVE 1 Licensing Program Analyst Dora Hesla conducted a case management visit at the above facility. In the 2 process of conducting that visit LPA Hesia was advised that the new Administrator of the facility was Heather 3 Sleuter, LPA Hesia received a call and was advised that Heather Sleuter did not meet the administrator 4 requirements..Heather Sleuter did not have a current Administrator Certificate and did not meet the education 5 and job experience requirements. 6 7 See 809D for Title 22 Regulations cited. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) PBS Front Line PRA Request 000088 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 ' VISIT DATE: 06/27/2013 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type B 06/28/2013 Section Cited 84064(b) Type B 06/28/2013 Section Cited 84064(e)(2) 1 Administrator Qualifications. Group homes shall O have certified administrators. 3 fThe facility has been without a Certified 5 Administrator since June 20, 2013 7 1 The administrator of a facility with a iicensed capacity of 13 or more children shali meet one of 3 the foiiowing requirements: 4 5 The facility administrator did not have a current 6 7 Administrator Certificate, and did not meet the education and job experience requirements. 1 Gordon Richardson or another qualified o administrator will be the Facility Administrator by 3 end of day, June 28, 2013 Gordon Richardson will submit a copy of the 5 Administrator Certificate, Copy of education f requirements,Board Resolution and Resume to 7 Thomas Stahl, No. Cal. Children's Residental Regional Manager by 4:00pm on June 28, 2013 Gordon Richardson will submit a copy of the Administrator Certificate, Copy of education 3 requirements,Board Resolution and Resume to Thomas Stahl, No. Cal. Children's Residental 5 Regional Manager by 4:00pm on June 28, 2013 6 7 11 22 33 44 55 66 77 11 22 33 44 55 66 77 Failure to correct the cited deftciency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Leon Wells TELEPHONE; (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013 k I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2013 . LC809 (FAS) - (06/04) Page: 2 of 2 PBS Front Line PRA Request 000089 STATE OF CALFORNA - HEALTH AMD HUMAN SERVICES AGENCY FACIL1TY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDR1E MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 TYPE OF VISIT: Case Management - Other CENSUS: 15 UNANNOUNCED MET WITH: Gordon Richardson Regional Executive Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/27/2013 01:25 PM 03:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA toured 2 the facility. LPA received a copy of the staff schedules. LPA received a copy of the facility census. 3 4 There are currently fifteen clients at the facility. Thirteen boys and two girls 5 6 Pioneer House- 4 clients and 3 staff 7 Trailblazer House- 3 clients and 3 staff 8 Voyager House- 6 clients and 3 staff 9 Sapphire House- 2 clients and 3 staff 10 11 Total 15 clients/12 staff 12 13 NO AWOL'S 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2013 i acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2013 This report must be available at Child Care and Group Home facilities for pubiic review for 3 years. LIC809 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000090 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Oflice, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33 ________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDR1E MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 15 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Taibou Dia- Regional Manager Administration FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 {530} 753-0220 95618 06/26/2013 04:15 PM 06:15 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 obtained copies of staff schedules. LPA obtained a copy of facility census. LPA toured the facility homes. LPA 3 checked food suppfy in all facility homes and facility kitchen. 4 5 NO AWOL'S 6 7 There are currently fifteen clients at the facility. Thirteen boys and two girls. 8 Out of the fifteen clients there are fourteen at the facility and one client on a home pass 9 10 Pioneer House: 3 clients and 3 staff 11 Traiiblazer House- 3 clients and 3 staff 12 Voyager House: 6 clients and 3 staff 13 Sapphire House: 2 clients and 3 staff 14 15 14 clients/12 staff 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) PBS Front Line PRA Request 000091 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLDRegional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 ______ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 15 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Audrie Meyer- Administrator____________________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/25/2013 04:30 PM 05:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA toured 2 the facility. LPA received copies of the staff schedules. LPA received a copy of the facility census. 3 4 The facility currently has fifteen clients, thirteen boys and two girts. 5 6 The facility currently has a ratio of 10 staff to 13 clients 7 Pioneer House- 2 staff, 3 clients 8 Trailblazer House- 2 staff, 3 clients 9 Voyager House- 4 staff, 5 clients 10 Sapphire House- 2 staff, 2 clients 11 12 Out of the 15 clients 2 clients are out on a home pass 13 14 NO AWOL'S 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916} 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916} 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICB09 (FAS) - (05(94) PBS Front Line PRA Request 000092 STATE OF CALIFORNIA - HEALTH ANO HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Ottica, 2525 NATOMAS PARK DRIVE ________________________________________________________________________________________ SACRAMENTO, CA 95833________ _____ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 16 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Audrie Meyer- Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/24/2013 04:00 PM 04:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility LPA obtained 2 copies of staff schedules and facility census. 3 4 There are currently 16 clients at the facility. Thirteen boys and three girls. 5 There are fourteen clients on campus and two clients on home pass. 6 7 Pioneer House- three staff and three clients 8 Ranger House- three staff and two clients 9 Trailblazer House- three staff and three clients 10 Voyager House- three staff and three clients 11 Sapphire House- three staff and three clients 12 13 15 staff/14 clients 14 15 NO AWOL's 16 17 Going to close Ranger house and move the clients to Voyager House either this evening or tomorrow. 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: l DATE: 06/24/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICBOg (FAS) - (06/04) PBS Front Line PRA Request 000093 STATE OP CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Ofllce, Z525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS; 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 18 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Rlchardson-Region Executive Director______ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/23/2013 09:45 AM 01:45 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA toured 2 the five homes that clients are occupying. 3 4 There are currently eighteen clients at the facility. Fourteen boys and four girls. There are currently thirteen 5 clients on campus and five clients on a home pass. One of the five clients that is currently on a home pass will 6 be returning to the facility at 1700 hours this evening. 7 8 No AWOL'S 9 10 Current client to staff ration is as follows. 11 Voyager House- three clients and three staff 12 Traiiblazer House- two clients and two staff 13 Ranger House- two clients and two staff 14 Sapphire House- three clients and two staff 15 Pioneer House- three clients and three staff 16 17 Total-12 staff/13 clients 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR /SIGNATURE: DATE: 06/23/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 {FAS) - (06/04) PBS Front Line PRA Request 000094 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 18 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Gordon Richardson- Regional Executive Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/22/2013 10:00 AM 02:00 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility, LPA toured 2 all of the facilities homes. LPA received the staff schedules. LPA received client census. 3 4 The facility currently has eighteen clients. Fourteen boys and four girls. Fourteen clients are on campus and 5 four clients are on home passes. 6 The facility currently has eleven staff assigned to the homes 8 Ranger House- three clients and two staff 109 Pioneer House- four clients and two staff Voyager House- four clients and two staff 11 Sapphire House- four clients and three staff 12 Trailblazer House- three clients and two staff 13 14 Al! of the homes were clean, safe sanitary and in good repair. All of the homes had two days of perishables 15 and one week of non-perishables. 16 17 The facility did not have any clients AWOL yesterday or last night. 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dora Hesia TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ------------------ DATE: 06/22/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - {06/04) PBS Front Line PRA Request 000095 STATE O f CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNiA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______ ____________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 19 TYPE OF VISIT: Case Management - Deficiencies UNANNOUNCED MET WITH:_____ Audrie Meyer- Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/21/2013 09:30 AM 12:30 PM NARRATIVE 1 Licensing Program Analyst Dora Hesia conducted a case management visit at the above facility. LPA 2 checked all of the food supplies at the following homes: Pioneer, Ranger, Trailblazer, Voyager and Sapphire. 3 LPA checked the food supply in the facility kitchen 4 5 The food supply in all of the above homes and kitchen meet the Title 22 Regulation. There was no expired 6 food and all food was correctly labeled and packaged. 7 8 Facility Administrator Audrie Meyer submitted a LIC 9098 to LPA Hesia. LPA Hesia has confirmed that the 9 plan of correction was completed. Facility still has to train all of their employees on proper food storage by 10 plan of correction date 6/28/2013 11 12 The current census at the above facility is 19 clients- 15 boys and 4 girls 13 14 The current staff to client ratio is as follows: 15 16 A2- Pioneer House- 5 clients and 2 staff 17 B1- Ranger House- 3 clients and 2 staff 18 C2- Trailblazer House- 3 clients and 2 staff 19 D1- Voyager House- 4 clients and 2 staff 20 D2- Sapphire House- 3 clients and 2 staff 21 22 The following homes are currently not occupied with clients: 23 C1 Adventure House 24 B2-Old Sapphire House 25 A1- Jade House SUPERVISOR'S NAME: Leon Wells LICENSING EVALUATOR NAME: Dora Hesia LICENSING EVALUATOR SIGNATURE: TELEPHONE: (916) 263-4711 TELEPHONE: (916) 216-9877 DATE: 06/21/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2013 PBS Front Line PRA Request 000096 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION r e p o r t CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSINO DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA95S33_____________ ______ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH:______ Audrie Meyer, Administrator____________________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED; 577000449 730 (530) 753-0220 95618 06/20/2013 01:45 PM 05:00 PM NARRATIVE 1 Licensing Program Analysts Staci Gorubec and Dora Hesia visited the above facility for the purpose of 2 monitoring staff to client ratios at the facility for this day. LPA obtained a staff schedule and current client 3 roster. There are currently 20 children in placement Throughout this day, including overnight staff, there are 4 9-14 staff on the facility grounds during each shift. LPA reviewed staff files and requested proof of staff 5 training. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000097 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95033 FACILITY NAME: FAMILIES FIRST INC, PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management -Deficiencies UNANNOUNCED MET WITH: Audrie Meyer, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/19/2013 11:00 AM 01:30 PM NARRATIVE 1 Licensing Program Analyst Staci Gorubec visited the above facility for the purpose of conducting a case 2 management visit pertaining to Title 22 deficiencies. On 6/6/13, LPA Gorubec and Complaint Specialist S 3 usan Sadler, toured the facility grounds. LPA and CS observed Title 22 deficiencies pertaining to food service 4 and storage at the facility. The following was observed in the main kitchen and/or house kitchens: 5 6 Food items with freezer burn (hamburger patties, waffles, pizza, tatertots, chicken nuggets) 7 Food items in pantry, refrigerator and freezer not stored properly-not sealed and/or iabeled 8 correctly(hamburger patties, meatballs, waffles, lunch meat, pie, taquitos, cream cheese, chicken strips, 9 battered fish patties, bread crumbs, individually packaged pasta with red sauce, raw chicken, prepared 10 taco meat, carrots in pickle jar, asparagus in pickle jar, green beans in pickle jar, yeast, flour tortillas, dry 11 cereal, oatmeal, flour out of original packaging, eggs, vegetables, ravioli, hash browns, tater tots, 12 Salisbury steak, hot dogs) 13 Expired food items in the refrigerator and pantry (lunch meat, salad dressing, baking powder, butter, 14 coconut, eggs, apples, oranges) 15 16 Deficiencies cited (Refer to 809D). Exit interview conducted. Appeal rights given. 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received, FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) PBS Front Line PRA Request 000098 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Oflice, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 0 6 /1 7 /2 0 1 3 and conducted by Evaluator Staci Gorubec CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20130617173403 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATORrAUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Audrie Meyer, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 9561B 06/19/2013 08:55 AM 11:00 AM ALLEGATION(S); Personal rights violated INVESTIGATION FINDINGS: 1 Licensing Program Analyst Staci Gorubec visited the above facility for the purpose of conducting an 2 unannounced 10 day visit. LPA reviewed a client file and obtained documentation. 3 4 Further investigation is needed. 5 6 7 8 190 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000099 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional o ffice , 2525 NATOMAS PARK DRIVE SACRAMENTO, CA95S33_______________________ FACILiTY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 06/19/2013 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 06/21/2013 Section Cited 80076(a)(1) Food Service. Foods shall be selected, stored, Some food items were discarded during 6/6/13 1 2 3 4 5 6 7 prepared and served in a safe and healthful 1 manner. Voyager house freezer continued-tater 2 tots with freezer bum and not labeled, sealed or 3 dated, Salisbury steak with freezer burn and not 4 sealed, hamburgers and hotdogs with freezer burn, ^ not labeled or dated, Sapphire house: ^ Refrigerator-expired eggs and mayonnaise. 7 Freezer-chicken nuggets not sealed and had visit. Faciiity will ensure ail expired and inappropriately labeled food ltems(lncluding those without dates) are discarded. Administrator will submit UC9098 certifying the corrections have been made, by POC due date. Facility will train ALL staff regarding proper food service. Proof of training will be submitted to CCL by 6/28/13. freezer bum, 8 9 10 11 12 13 14 vegetables not labeled or dated, ravioli not sealed 8 or labeled, waffles not fabeled or dated. Adventure 9 house: Refrigerator- individual packets of cream 10 cheese not dated. Freezer-chicken strips, meat 11 patties and other frozen items not labeied properly. 12 Jade House: Refrigerator-expired butter, 3 bottles 13 of expired salad dressing. Freezer-meat patties not 14 labeled. Type A 06/21 /2013 Section Cited 80076(a)(1) Pioneer house: Refrigerator- individual packets of 1 cream cheese not dated, Pantry-2 bottles of 2 3 4 5 6 7 expired salad dressing, dry cereal (out of original packaging) not labeled or dated, flour In large plastic container not labeled, individual packets of oatmeal in a box with expiration date removed, Trailblazer house: Expired bottle of Ensure In kitchen cupboard. Refrigerator- unknown food In pie dish not covered, labeled or dated, aslan dressing labeled without a date, Some food Items were discarded during 6/6/13 1 visit. Facility will ensure all expired and 2 Inappropriately labeled food items(includlng those 3 4 5 6 7 without dates) are discarded. Administrator will submit LIC9098 certifying the corrections have been made, by POC due date. Facility wilt train ALL staff regarding proper food service. Proof of training wiil be submitted to CCL by 6/28/13, 8 expired butter, 3 ziploc bags of vegetables not 9 labeled or dated, moldy lunch meat with not dates 10 or labels, sliced cheese with no dates or labels, 11 Chinese take out not labeled or dated. 12 Freezer-meatballs not sealed properly. 13 14 8 :9 10 11 12 13 14 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment, SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILiTY REPRESENTATIVE SIGNATURE: DATE: 06/19/2013 PBS Front Line PRA Request 000100 PBS Front Line PRA Request 000101 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2S25 NATOMAS PARK DRIVE SACRAMENTO, CA95S33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 06/19/2013 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 06/21/2013 Section Cited 80076(a)(1) 1 Food Service. Foods shall be selected, stored, 2 prepared and served in a safe and healthful 3 4 5 6 manner. Observed expired and/or unlabeled or incorrectly labeled food items in the refrigerators, freezers, and pantry. Food items in freezers had freezer burn. Main kitchen: open bread crumb 7 container with broken lid, expired baking powder, 1 Some food items were discarded during 6/6/13 2 visit. Facility will ensure all expired and 3 inappropriately labeled food items(including those 4 without dates) are discarded. Administrator will 5 submit LIC9098 certifying the corrections have g been made, by POC due date. Facility will train 7 ALL staff regarding proper food service. Proof of training will be submitted to CCL by 6/28/13. 8 expired coconut, seasoning with no label. 8 9 10 11 Refrigerator- Raw chicken thawing in ziploc bag with no label or dates, prepared spaghetti in trays with no dates or label, carrots, asparagus, green 9 10 11 12 beans in separate pickle jars with no label or dates, 12 13 prepared taco meat with no label or date, 2 rotting 13 14 oranges, 2 rotting apples, rotting cilantro, rotting 14 itaiian parsley, rotting jalapeno, Type A 06/21/2013 Section Cited 80076(a)(1) Food Service, Foods shall be selected, stored, Some food items were discarded during 6/6/13 1 prepared and served in a safe and healthful 1 visit. Facility will ensure ail expired and 2 manner. Main kitchen refrigerator continued: yeast 2 inappropriately labeled food items(including those 3 in plastic tennis ball container, flour tortillas not 3 without dates) are discarded. Administrator wili 4 labeled or sealed properly. Freezer- 2 bags of 4 submit LIC9098 certifying the corrections have 5 fish/chicken (breaded) not labeled or sealed 5 been made, by POC due date. Facility will train 6 properly, raw cubed meat in ziploc not labeled or 6 ALL staff regarding proper food service. Proof of 7 dated. 2 bags of cooked pasta not labeled or dated 7 training will be submitted to CCL by 6/28/13. hamburger patties in a box and bag not sealed with 8 freezer burn, chicken strips not sealed, taquitos out 8 9 of original packaging not iabeled, Voyager house: 9 10 Refrigerator- eggs not in carton with no date. 10 11 Freezer- hash browns not sealed, dated or iabeled, 11 12 chicken nuggets not sealed and had freezer burn, 12 13 biscuits and pizza with freezer burn, chicken filets 13 14 with freezer bum and not labeled, dated or sealed 14 properly, Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2013 PBS Front Line PRA Request 000102 LIC809 (FAS) - (06/04) Page 3 of 3 PBS Front Line PRA Request 000103 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Audrie Meyer, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/19/2013 01:30 PM 02:30 PM NARRATIVE 1 Licensing Program Analyst Staci Gorubec visited the above facility for the purpose of monitoring staff to client 2 ratios at the facility for this day. LPA obtained a staff schedule and current client roster. There are currently 3 23 children in placement. Throughout this day, including overnight staff, there are 11-20 staff on the facility 4 grounds during each shift. 5 6 7 8 190 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2013 l acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. L1C809 (FAS} - (06/04) Pa9e: 1 of 1 PBS Front Line PRA Request 000104 STATE OF CALPFORNIA- HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH:______Administrator, Audrie Meyer_______ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/18/2013 11:30 AM 02:30 PM NARRATIVE Complaint Specialist, Susan Sadler met with Administrator, Audrie Meyer to conduct Case Management Visit. 2 The purpose of the visit was to assess the operations of the facility. During the visit today, CS spoke to the 3 Administrator and reviewed incident reports. CS was provided current listing of ail clients, current census 24 4 with 11 staff to cover all shifts. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 {FAS) - (06/04) Pa96: 1 of 1 PBS Front Line PRA Request 000105 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA95B33_____________ FACILITY NAME; FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR; AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: 28 TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH:______ Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/14/2013 11:00 AM 12:45 PM NARRATIVE 1 Licensing Program Analysts (LPA) Maria Mayorga and Zenobia Bradley conducted a case 2 management visit on today's date. During today's visit LPAs toured all the houses and checked the 3 food supply. LPAs obtained current staff schedules and a current client census. LPAs observed an 4 5 adequate food supply for the current census. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Zenobia Bradiey TELEPHONE: (916) 216-9879 LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICB09 (FAS) - (06/04) Pa9e: 1 of 1 PBS Front Line PRA Request 000106 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA95B33_______ _____ This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/14/2013 and conducted by Evaluator Zenobia Bradley CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20130614101906 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/14/2013 01:00 PM 02:40 PM ALLEGATION(S): Lack of supervision which resulted in child injury INVESTIGATION FINDINGS: 1 Licensing Program Analysts (LPA) Maria Mayorga and Zenobia Bradley conducted the 10 day visit to the 2 facility. 3 4 Further investigation is needed. 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: {916} 263-4700 LICENSING EVALUATOR NAME: Zenobia Bradley TELEPHONE: (916) 216-9879 LICENSING EVALUATOR SIGNATURE: iJ^V DATE: 06/14/2013 1acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC8099 (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000107 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR;AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH: Administrator, Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/13/2013 11:30 AM 03:30 PM NARRATIVE 1 Complaint Specialist, Susan Sadler met with Administrator, Audrie Meyer to conduct Case Management Visit. 2 The purpose of the visit is to review staff and client files. Documents were obtained. Agency provided staff 3 schedule for current week. Current census 39 clients. 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: AJ_ (M'i'iiyr DATE: 06/13/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC80S (FAS) - (08/04) PBS Front Line PRA Request 000108 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Deficiencies UNANNOUNCED MET WITH:______ Audrie Meyer, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/12/2013 08:15 AM 12:45 PM NARRATIVE 1 Licensing Program Analyst Staci Gorubec visited the above facility for the purpose of conducting case 2 management visit pertaining to deficiencies observed during the course of an unrelated investigation. LPA 3 toured the facility and obtained residents' needs and services plans, on 6/6/2013, observing multiple Title 22 4 deficiencies. 5 6 Title 22 deficiencies cited (Refer to 809D). Exit interview conducted. Appeal rights given. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) Paget 1 of 5 PBS Front Line PRA Request 000109 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 85833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 06/12/2013 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type B 07/10/2013 Section Cited 80087(a) 1 Buildings and Grounds. The facility shail be kept 2 dean, sanitary and in good repair at all times. Roil 3 top window in kitchen area is dirty with food 4 particles. Adventure house: living room blinds was 5 missing a slat and had on broken slat; the couch 6 under the window was broken; bathroom 2 did not 7 have a toilet paper holder. 1 Facility wifi repair/repiace/clean all items listed. 2 Facility will submit completed work orders as well 3 as UC9098 certifying the corrections have been 4 made, to CCL by COB by POC due date. 5 6 7 8 Sapphire house: both bathrooms did not have a 8 9 toilet paper holder. Voyager house: Both 9 10 bathrooms did not have toilet paper holders. 10 11 Trailblazer house: The Sight for the shower area 11 12 was not working; A roll of toilet paper was observed 12 13 on the bathroom floor by the toilet. 13 14 14 11 22 33 44 55 66 77 11 22 33 44 55 66 77 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916} 263-4809 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916} 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2013 LICB9 (FAS) - (06/04) Page: Ao f 5 PBS Front Line PRA Request 000110 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633_______________________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/11/2013 and conducted by Evaluator Staci Gorubec CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20130611024221 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Jennifer Cass, Director of Quality Assurance FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/11/2013 10:15 AM 10:45 AM ALLEGATION^): Children's Personal Rights were violated Children are not being properly supervised INVESTIGATION FINDINGS: 1 Licensing Program Analyst Staci Gorubec visited the above facility for the purpose of conducting an 2 unannounced 10 day visit. Facility was informed of the allegations. 3 4 Further investigation is needed. 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: " DATE: 06/11/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000111 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 2525 NATOMAS PARK DRIVE ________________________________________________________________________________________SACRAMENTO, CA 95833_________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Other UNANNOUNCED MET WITH:______ Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 05/23/2013 04:01 PM 05:00 PM NARRATIVE 1 A consultation with the Administrator took place with regards to the facility and their restraint practices. In 2 addition, the issues with children AWOLing and the Davis PD's response to their reporting requirements was 3 discussed. The Administrator reports that they have increased training for floor staff from once a month to 4 once a week. The facility has a current capacity of 63 residents. It is advised that the facility immediately hire 5 additional staff and have a higher level of supervision in order to address the reduced restraint model 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Julie Darden LICENSING EVALUATOR NAME: Ashley Srnclatre LICENSING EVALUATOR SIGNATURE: TELEPHONE: (916) 263-4809 TELEPHONE: (916) 508-9726 DATE: 05/23/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE; 05/23/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS} - (06/04) Pa9e: 1 of 1 PBS Front Line PRA Request 000112 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, C A 95833____________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/03/2013 and conducted by Evaluator Ashley Sinclaire PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20130403092948 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Steve Lendzlon FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 {530) 753-0220 95618 05/23/2013 03:15 PM 04:00 PM ALLEGATION (S): Personal Rights Violation-Client was used to demonstrate a restraint. INVESTIGATION FINDINGS: 1 SUBSTANTIATED 2 3 LPA, Ashley Sinclaire investigated the above allegation and substantiated it. Files were reviewed and 4 documents were obtained. Interviews were conducted with the Administrator, Program Coordinator, Senior 5 Staff Trainer, Staff Trainer, the biological father of one resident and also the two residents alleged to have been 6 involved in the inappropriate practice. It was determined that one resident was used to demonstrate restraints 7 during a tour of the facility by medical personnel. This restraint demonstration was not conducted by an 8 untrained individual but the Senior Trainer himself. Although the child was not physically harmed it was a 9 violation of the resident's personal rights to be unnecessarily restrained. Therefore, the complaint is 10 substantiated. 11 12 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 {FAS} - {06/04) Page: 1 of 2 PBS Front Line PRA Request 000113 Control Number 23-CR-20130403092948 STATE OF CALIFORNIA - HEALTH ANO HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE- 05/23/2013 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A nfi/pa/po-i 3 Section Cited 84072(c) (13) Type A 05/31/2013 84072(c)(14) 1 Personal Rights-Personal rights include dignity in 1 No child will be utilized to demonstrate a restraint 2 personal relationships with staff and other persons, 2 or be restrained unless it is directly related to the 3 -Client was used to demonstrate an unnecessary 3 child's behavior that warrants physical intervention. 4 5 restraint for the public. 4 5 Submit policy statement to CCL by due date. 66 77 1 Personal Rights. Personal rights include the right 2 to live in a safe, healthy, and comfortable home 3 where he or she is treated with respect. 4 -Client was used to demonstrate an unnecessary b restraint for the public. 6 7 1 All staff will be trained In restraint protocol. Submit 2 a signed document for each employee that 3 acknowledges they attended training and 4 understand they cannot restrain clients under any 5 circumstances unless the intervention is warranted 6 due to the clients' behavior. 7 11 22 33 44 55 66 77 11 22 33 44 55 66 77 Failure to correct the cited deficiency{ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2013 LIC9099 (FAS) - (06/04) Page: 2 of 2 PBS Front Line PRA Request 000114 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OP SOCIAL SERVICES COMMUNITY CARE LICENSING DIVtSION CCLD Regional Otfice, 2625 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/06/2013 and conducted by Evaluator Ashiey Sinclaire CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20130506154733 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Michele Bottega FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 05/09/2013 01:45 PM 05:30 PM ALLEGATION(S): Personal Rights INVESTIGATION FINDINGS: 1 TEN DAY VISIT 2 3 LPA, Ashley Sinclaire made an unannounced visit to the facility today to open the complaint. Interviews were 4 conducted with the Program Coordinator, the Case Manager, and seven residents | 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2013 i acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2013 t / 1/ t This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06(04) Page: 1 of 1 PBS Front Line PRA Request 000115 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833____________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/17/2013 and conducted by Evaluator Ashley Sinclaire CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20130417172748 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH:______ Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 04/24/2013 02:00 PM 03:30 PM ALLEGATIONS): 1 Food Service 2 3 4 5 6 8 9 INVESTIGATION FINDINGS: 1 TEN DAY VISIT 2 3 LPA, Sinclaire made an unannounced visit to the facility today to open the complaint. Files were reviewed and 4 documents were obtained. Interviews were conducted with the facility Administrator and the Program 5 Supervisor who oversees food ordering and distribution for the facility. 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000116 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33 This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/03/2013 and conducted by Evaluator Ashley Sinclalre COMPLAINT CONTROL NUMBER: 23-CR-20130403092948 FACILITY NAME: FAMILIES FIRST INC, PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH:______ Audrie Meyers FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530} 753-0220 95618 04/09/2013 01:00 PM 05:00 PM ALLEGATION(S): Personal Rights Personnel Requirements INVESTIGATION FINDINGS: 1 TEN DAY VISIT 2 3 LPA, Ashley Sinclaire made an unannounced visit to the facility today to open the investigation, interviews were 4 conducted with the Administrator, two Staff Trainers and the Program Coordinator. Further investigation is 5 needed. 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) - (06/04) Page: 1 oi 2 PBS Front Line PRA Request 000117 STATE OF CAUFORMIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Incident UNANNOUNCED MET WITH: Audrie Meyer________________________________ FACILITY NUMBER: FACILITY TYPE* ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 {530} 753-0220 95618 02/25/2013 10:30 AM 02:00 PM NARRATIVE 1 LPA, Ashley Sinclaire made an unannounced case management visit to the facility today for a follow up on an 2 incident report and also to conduct an inspection of the residential homes. Documents were obtained and 3 interviews were conducted with the Administrator, a social worker and the Senior Learning Partner. In 4 addition, a consultation took place regarding Title 22 regulations as it pertains to restraints, the doors of the 5 quiet room, AWOL's, Davis PD response to the facility's missing children and an additional incident involving 6 texting between a resident and staff. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC80B (FAS) - (06/04) Page: 1 of t PBS Front Line PRA Request 000118 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 5B33 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/26/2012 and conducted by Evaluator Susan Sadler COMPLAINT CONTROL NUMBER: 23-CR-20120926161325 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Clinical Director, Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/30/2013 11:00 AM 01:00 PM ALLEGATION^): Personal Rights Violation INVESTIGATION FINDINGS: 1 Complaint Specialist, Susan Sadler met with Clinical Director, Audrie Meyer to conduct Complaint Visit. CS 2 interviewed staff and reviewed files. Advised further investigation is required. 3 4 5 6 7 8 9 10 11 12 13 Needs Further Investigation__________________________________________ Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: M . S C **& n DATE: 01/30/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. PBS Front Line PRA Request 000119 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOWIAS PARK DRIVE SACRAMENTO, CA 95633 __________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/26/2012 and conducted by Evaluator Susan Sadler COMPLAINT CONTROL NUMBER: 23-CR-20120926161325 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/29/2013 11:30 AM 01:00 PM ALLEGATION^): Personal Rights Violation INVESTIGATION FINDINGS: 1 Complaint Specialist, Susan Sadler met with Clinical Director, Audrie Meyer to conduct Complaint Investigation. 2 CS interviewed staff. Agency facilitator of the files is not available. CS will make a return visit to review files. 3 CS advised further investigation is required. 4 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2013 MMP* I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000120 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33 FACILITY NAME: FAMILIES FIRST INC, PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT : Case Management - Deficiencies UNANNOUNCED MET WITH:______ Michele Bettega______________________________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/10/2013 02:20 PM 03:45 PM NARRATIVE 1 Complaint Specialist Dawn Eunice conducted a case management inspection to the above facility for the 2 purpose of ensuring compliance with Title 22 regulation. 3 4 CS became aware that the restraint of a resident was not justified and was not executed properly. Families 5 First Inc. utilizes the Pro Act method of restraining a child when the child becomes a danger to themselves or 6 others. Based on a statements in interviews and based on incident reports, the child's behavior did not 7 warrant the restraint. A child was restrained before other non-physical interventions were attempted. During 8 this restraint the child sustained a serious injury. The child suffered a fracture of the radius and ulna on the 9 right arm. The child had surgery to repair both fractures in the arm. This is contradictory to the emergency 10 intervention plan and in violation of the child's personal rights. 11 12 See LIC 809D for personal rights and plan of operation Title 22 regulation violations cited. 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Weils TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunce-MacLean ` TELEPHONE: {916} 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICB09 (FAS} - (06/04) Page; 1 of 2 PBS Front Line PRA Request 000121 STATE OF CALIFORNIA - HEALTH AMO HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 ____ This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/ 18/2012 and conducted by Evaluator Dawn Eunice-MacLean COMPLAINT CONTROL NUMBER: 23-CR-20121018154400 FACILfTY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Michele Bettega FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/10/2013 03:45 PM 04:00 PM ALLEGATION^): Physical Abuse INVESTIGATION FINDINGS: 1 Complaint Specialist Dawn Eunice conducted complaint inspections to the above facility. CS reviewed 2 children's files, staff files, a child's medical reports, and incident reports. CS obtained copies of relevant 3 documentation. CDSS Investigator Tami Adge completed the investigation which included an interview with a 4 child's biological mother, the GH administrator, a child, ex-staff members and a doctor. The evidence aiso 5 included a police report and medical records from a hospital. 6 7 A child sustained broken bones, which required surgery, as a result of an inappropriate/improper restraint. It is 8 unclear whether staff intentionally caused the injury, if staff exercised very poor judgment in the moment, or, if 9 staff broke the child's bones by accident. Although physical abuse may have happened there is not a 10 preponderance of the evidence to substantiate. 11 12 The allegation is INCONCLUSIVE. CS Eunice delivered this finding 1-10-13. 13 Inconclusive Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunice-MacLean TELEPHONE: (916) 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 {FAS} - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000122 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 85B33______________________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 07/05/2012 and conducted by Evaluator Brandy Griffin PUBLIC COMPLAINT CONTROL NUMBER; 23-CR-20120705084136 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHALEWiS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: ANNOUNCED MET WITH: Michelle Bettega, Program Coordinator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: ALLEGATION(S): Child's personal rights were violated. 577000449 730 (530} 753-0220 95618 01/08/2013 09:00 AM 10:00 AM INVESTIGATION FINDINGS: 1 Licensing Program Analyst Brandy Griffin conducted a visit to the agency for the purpose of closing a complaint 2 and delivering findings pertaining to the allegations above. LPA Griffin reviewed client files and interviewed 3 staff, bio mother, county social worker and the client. It was reported that staff prevented bio mom from 4 contacting client during two scheduled visits, social worker refused to let client have pictures that bio mom 5 brought to a visit and client's education was compromised due to social worker disclosing confidential 6 information regarding client's removal from home to his new school. Investigation revealed inconsistent 7 statements. Social worker was unable to be located for interview and no longer works at the facility. We 8 therefore find the allegations INCONCLUSIVE. 9 10 11 12 13 Inconclusive SUPERVISOR'S NAME: Julie Darden Estimated Days of Completion: TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Brandy Griffin TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: _ .V r ^ DATE: 01/08/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS} - (06/04} PsgB: 2 of 2 PBS Front Line PRA Request 000123 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ This is an official report of an unannounced visit/investigation of a compiaint received in our office on 07/05/2012 and conducted by Evaluator Brandy Griffin COMPLAINT CONTROL NUMBER: 23-CR-20120705084136 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Michelle FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE; TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/07/2013 09:45 AM 01:00 PM ALLEGATION(S): Childs personal rights were violated. Facility failed to provide care and supervision. INVESTIGATION FINDINGS: 1 Licensing Program Analyst Brandy Griffin conducted a visit to the agency for the purpose of closing a 2 compiaint. A file request was made during the visit, due to time constraints LPA Griffin had to leave the facility 3 and return tomorrow morning a 9am to close the complaint and deliver findings. 4 5 Further investigation is needed. 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Brandy Griffin TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: 'b DATE: 01/07/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS} (06/04) Page: 1 of 2 PBS Front Line PRA Request 000124 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT; Required - 5 Year UNANNOUNCED MET WITH:_____ Michele Bettega FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/02/2013 11:47 AM 06:00 PM NARRATIVE 1 LPA, Ashley Sincfaire made an unannounced visit to the facility to conduct a required five year annual 2 inspection. The facility review was facilitated by the Program Coordinator of the Day Treatment Program, 3 Michele Bettega. I met with a member of the Human Resource staff and both staff and client files were 4 reviewed. The files were found to be impeccable with no deficiencies cited. All adults subject to background 5 checks were found to be fingerprint cleared. This Level 13/14 facility has recently reduced their capacity from 6 72 to 63 and currently have 59 placements. They were recertified on July 1,2012 by the State Department of 7 Alcohol, Drug and Mental Health Services in order to continue to provide mental health treatment to their 8 clients . The Yolo county Fire Marshall also inspected the facility on 9/12/12 and issued an updated fire 9 clearance. A fully accredited non-public school is on the grounds which is part of the Washington Unified 10 School District. They have ten classrooms and teach the third through the twelfth grades. The campus 11 consists of an Administration building, the Program office, a gymnasium, art room and the Resource Center 12 where the medication was found to be appropriately locked according to Title 22 regulations. Monsanto 13 recently donated eight raised garden beds and In the spring time the staff assist the clients in planting 14 vegetable and flower gardens in the back of each residential house. 15 16 Events for the children include March Madness which is a basketball tournament that lasts a week and takes 17 place on their regulation basketball court. Also, there is an Olympic event that runs for two weeks that is held 18 on and off sight within the city of Davis At the conclusion of these events a family awards ceremony and a 19 dinner is given. Other notable recreational activities Include a variety show with family participation, the 20 annual Halloween Carnival, an Easter program, a July 4th celebration and observance of the Thanksgiving 21 and Christmas holidays. 22 23 There are currently 7 residential houses on the campus but only six are occupied. The six occupied houses 24 were inspected and numerous physical plant violations were observed. All toxics within the houses were 25 SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) (05/04) PBS Front Line PRA Request 000125 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNSTY CARE UCENSING DIV!S(ON CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC . TREATMENT FACILITY NUMBER: 577000449 ______________________________________________________________________ VISIT DATE: 01/02/2013 NARRATIVE Page 2, annual continued 2 3 locked and inaccessible to the clients. There are no bodies of water or firearms at the facility. The food supply 4 was adequate in all of the houses and the temperatures were within regulation. 5 6 7 The following Title 22 violations were noted within the six residential houses that were inspected: 8 9 Trallblazer House 10 11 -The carpet is worn and dirty throughout the house. 12 -The refrigerator is dirty, 13 -The blue upholstered chairs throughout the facility are dirty, stained and not in good repair. 14 -T he blue couches in the main area have exposed support springs beneath the cushions. 15 -Debris, including dirty socks were seen underneath the couch. 16 -The laundry room has a chipped counter top. 17 -There was a pile of clothing left in the hallway. 18 -Hallway counter top is chipped. 19 -The red futon in the hallway is stained and dirty. 20 -The facility needs painting. 21 -All bedrooms but the second bedroom were in a disarray and not clean . 22 -There were flattened, cardboard boxes obstructing the emergency exit. 23 24 Pioneer House 25 26 -Refrigerator is dirty. 27 -There were spoiled oranges and potatoes on the kitchen counter available to the residents. 28 -The blue chairs and couches are stained and dirty. 29 -Outside of the emergency exit there were dirty diapers in plastic bags laying on the ground. 30 31 32 SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Slnclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 LIC809 (FAS) - (06/04) Page: 2 of 5 PBS Front Line PRA Request 000126 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Ofiice, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT FACILITY NUMBER: 577000449 _________________________________________________________________________ VISIT DATE: 01/02/2013 NARRATIVE 1 Page 3, annual continued 2 3 Jade House 4 5 -The blue upholstered chairs and couches are stained, dirty and not in good repair. 6 -The refrigerator Is dirty. 8 Ranger House 9 10 -The blue upholstered chairs are dirty and stained. 11 -The refrigerator is dirty. 12 -The sink is severely stained and marred. 13 -The carpet is dirty and worn throughout the facility. 14 -All pedestal beds have chipped paint. 15 -There was used toilet paper on the floor of the bathroom. 16 -The linoleum is chipped on the floor in the hallway. 17 -The kitchen counter top Is chipped. 18 -The house was in a disarray and not clean. 19 20 Adventure House 21 22 -The kitchen countertop is chipped. 23 -The refrigerator is dirty. 24 -There was a leaking water container in the refrigerator. 25 -The blue upholstered chairs throughout the facility were stained and dirty. 26 27 Vovaaer House 28 29 -The facility needs painting throughout. 30 -The carpet is worn and dirty. 31 32 SUPERVISOR'S NAME: Julie Darden TELEPHONE: {916} 263-4809 LICENSING EVALUATOR NAME: Ashley Sinciaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 7 ry & 4 r \ LICB09 (FAS) - (06/04) Page: 3 of 6 PBS Front Line PRA Request 000127 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT FACILITY NUMBER: 577000449 ______________________________________________________________________ VISIT DATE: 01/02/2013 NARRATIVE 1 Page 4, annual continued 2 3 -The green and blue upholstered chairs and couches throughout the facility are stained and dirty. 4 -The kitchen sink is chipped 5 -The refrigerator is dirty. 6 -All bedrooms but one are in a disarray and not clean. 7 8 Sapphire House 9 10 -The facility was in a disarray and not clean. 11 -The blue and green upholstered chairs are stained and dirty. 12 -The entire facility needs to be painted. 13 -The refrigerator is dirty, 14 -The kitchen sink is stained and scarred. 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 LIC809 (FAS) - (05/04) Page: 4 of 5 PBS Front Line PRA Request 000128 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/01/2012 and conducted by Evaluator Ashley Sinclaire PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20121101105536 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE, CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Michele Bettega FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/02/2013 11:00 AM 11:45 AM ALLEGATI ON(S): Personal Rights-Child was subjected to an inappropriate restraint by two staff. INVESTIGATION FINDINGS: 1 Inconclusive 2 LPA, Ashley Sinclaire investigated the above allegation and found it to be inconclusive. The client's file was 3 reviewed and documentation was obtained from the facility. Interviews were conducted with the Administrator, 4 the Senior Learning Partner, the Residential Social Worker, the Program Coordinator for Day Treatment 5 Intensive, the Supervisor for Jade House, a counselor who participated in the restraint and a resident who 6 witnessed part of the restraint. The client states that the staff were restraining her because she was trying to AWOL. However the staff states that she was swinging a broken wooden rod at them and that is why she was 8 restrained. The client states she was injured during the restraint and did not receive appropriate medical care. 9 However, once staff learned she had complaints she was seen by medical personnel. There are conflicting 10 accounts of what happened during the restraint and there is not enough testimony or evidence to discern 11 whether the restraint was conducted properly. Therefore, the allegations are inconclusive. 12 13 Inconclusive Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 Of 2 PBS Front Line PRA Request 000129 LIC9099 (FAS) - (06/04) Page: 2 of 2 PBS Front Line PRA Request 000130 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______ This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/19/2012 and conducted by Evaluator Ashley Sinclaire __________________ PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20121119162649 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Michele Bettega FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: ALLEGATION(S): Personal Rights-Resident was treated in a disrespectful manner by staff. 577000449 730 (530) 753-0220 95618 01/02/2013 10:00 AM 10:45 AM INVESTIGATION FINDINGS: 1 SUBSTANTIATED 2 3 LPA, Ashley Sinclaire investigated the above allegation and substantiated it. Files were reviewed and 4 interviews conducted with both staff and residents, it was determined that several staff had spoken to 5 residents in a rude manner on numerous occasions. Further, it was disclosed that staff were frequently 6 sarcastic or demeaning towards certain clients and non- responsive or dismissive when asked to meet clients' 7 emotional needs. In addition, staff did not treat clients in a fair and impartial manner, often giving negative 8 feedback and sanctions to some and yet behaving positively towards and granting special privileges to others. 9 It was also learned that staff had placed a piece of duck tape down the center of one client's room as a punitive 10 measure. 11 12 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 Of 2 PBS Front Line PRA Request 000131 Control Number 23-CR-20121119162649 STATE OF CALfFORNfA - HEALTH AND HUMAN SERVfCES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE- 01/02/2013 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 01/16/2013 Section Cited 84072C13 14 16 Personal Rights-Personai rights include dignity in Ali staff will be trained in Title 22 regulations as it personal relationships with staff and other persons; pertains to personal rights. In addition, training for 1 the right to live in a safe, healthy, and comfortable 1 all Jade House staff involved in the incident in 2 home where he or she is treated with respect; fair 2 proper ways to respond to ciients with emotional 3 and equal access to all available services, 3 issues will be conducted. Sign in sheets along with 4 placement, care, treatment, and benefits, and to be 4 the subjects that were covered will be submitted to 5 free from discrimination or harassment on the basis 5 CCL by the 1/16/13. 6 of actual or perceived mental or physical disability. 6 7 -Clients were treated disrespectfully, their 7 emotional needs were not met and were denigrated for their mental disabilities. 11 22 33 44 55 66 77 11 22 33 44 55 66 77 11 22 33 44 55 66 77 Failure to correct the cited defEciency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2013 PBS Front Line PRA Request 000132 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, C A 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/19/2012 and conducted by Evaluator Ashley Sinclaire CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20121119162649 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 12/05/2012 02:00 PM 04:00 PM ALLEGATIONS): Personal Rights INVESTIGATION FINDINGS: 1 Needs Further Investigation 2 3 LPA, Ashley Sinclaire made an announced visit to the facility today to interview multiple staff regarding the 4 allegations. 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page; 1 of 1 PBS Front Line PRA Request 000133 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALEFORNfA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LECENSING DIVISION CCLD Regional Office, 2S25 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33 This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/01/2012 and conducted by Evaluator Ashley Sinclaire COMPLAINT CONTROL NUMBER: 23-CR-20121101105536 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: MET WITH:______ Audrie Meyer UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: ALLEGATION(S) : Personal Rights 577000449 730 (530) 753-0220 95618 12/05/2012 04:15 PM 06:00 PM INVESTIGATION FINDINGS 1 Needs Further Investigation 2 3 LPA, Ashley Sinclaire made an announced visit to the facility today to interview multiple staff and one client. 4 5 6 7 8 9 10 11 12 13 Needs Further investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000134 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/19/2012 and conducted by Evaluator Ashley Sinclaire CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20121119162649 FACILITY NAME: FAMILIES FIRST INC, PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 11/29/2012 02:10 PM 04:30 PM ALLEGATION (S) : Personal Rights INVESTIGATION FINDINGS: 1 LPA, Ashley Sinclaire made an unannounced ten day visit to the facility today to open the complaint. The 2 client's file was reviewed and an interview was conducted with the client and the facility Administrator. 3 4 5 6 7 8 9 10 11 12 13 Needs Further Investigation SUPERVISOR'S NAME: Julie Darden Estimated Days of Completion: TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 508-9726 LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACiLITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) - (06/04) Page; , of , PBS Front Line PRA Request 000135 STATE OF CALIFORNIA * HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95033 This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/01/2012 and conducted by Evaluator Ashley Sinclaire CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20121101105536 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH : Courtney Ghilain FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 11/02/2012 12:00 PM 03:30 PM ALLEGATION(S): Personal Rights-lmproper restraint INVESTIGATION FINDINGS: 1 TEN DAY VISIT 2 3 LPA, Ashley Sinclaire made an unannounced visit to the facility today to open the complaint. Files were 4 reviewed and doumentation was obtained. Interviews were conducted with the group home client, the Senior 5 Learning Partner, the Residential Sociai Worker and the Program Coordinator for Day Treatment Intensive. 6 8 9 10 11 12 13 Needs Further Investigation SUPERVISOR'S NAME: Julie Darden LICENSING EVALUATOR NAME: Ashley Sinclaire LICENSING EVALUATOR SIGNATURE: Estimated Days of Completion: TELEPHONE: (916) 263-4809 TELEPHONE: (916) 838-8919 DATE: 11/02/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: If DATE: 11/02/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9QB9 (FAS} - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000136 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 _________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/18/2012 and conducted by Evaluator Dawn Eunice-MacLean PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20121018154400 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH:______Audrie Meyer, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 10/24/2012 09:30 AM 04:30 PM ALLEGATION(S): Reporting Requirements - Injury not reported INVESTIGATION FINDINGS: 1 Complaint Specialist Dawn Eunice conducted the 10-day complaint inspection to the above facility. CS 2 reviewed incident reports subject to the complaint. CS reviewed a child's file. CS met with Ms. Meyer, the 3 Interim Clinical Director. 4 5 Regulation 80061 mandates any injury to a client which requires medical treatment be reported to the licensing 6 agency within the agency's next working day during its normal business hours. A child sustained a significant 7 injury during a restraint. The restraint was timeiy reported; the child's injury sustained during the restraint which 8 required medicai treatment was not. 9 10 Due to the foregoing, the above allegation is SUBSTANTIATED. See LIC 9099D to Title 22 regulation cited. 11 CS conducted exit interview, provided a printed copy of Regulation 80061, and provided appeal rights. 12 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunice-MacLean TELEPHONE: (916) 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) - (06/04) Page: 1 Df 3 PBS Front Line PRA Request 000137 Control Number 23-CR-20121018154400 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 10/24/2012 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type B 10/31/2012 Section Cited 80061(b)(1)(D) 1 80061(b)(1)(D) Reporting Requirements. 2 q Regulation mandates incidents involving client 1 GH Administrative staff shall provide incident 2 reporting training to relevant individuals. 9 4 5 6 injury requiring medical treatment be made to CCL within the next working day during business hours, A child sustained a significant injury to his arm 4 6 GH staff shall provide plan of correction to CS Eunice by 10-31-12. The pian shall include individuals who attended the training and its 7 during a restraint. The restraint was timely reported; the injury was not. content. 11 22 33 44 55 66 77 11 22 33 44 55 66 7 11 22 33 44 55 66 77 Failure to correct the cited deficlency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunice-MacLean TELEPHONE: (916) 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2012 Sacknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2012 LIC9099 (FAS) - (06/04) Page: 2 of 3 PBS Front Line PRA Request 000138 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 9SS33 This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/18/2012 and conducted by Evaluator Dawn Eunice-MacLean COMPLAINT CONTROL NUMBER: 23-CR-20121018154400 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAViS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Audrie Meyer, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: ALLEGATION^): Personal Rights 577000449 730 (530) 753-0220 95618 10/24/2012 09:30 AM 04:30 PM INVESTIGATION FINDINGS: 1 Complaint Specialist Dawn Eunice conducted the 10-day complaint inspection to the above facility. CS 2 reviewed incident reports subject to the complaint. CS reviewed children and staff files. CS obtained copies of 3 relevant documentation. 4 5 CS met with Ms. Meyer, the interim Clinical Director, and advised her the investigation would be completed at a 6 later date by CDSS investigator Tami Adge. 7 8 This report is created to document this inspection. 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunice-MacLean TELEPHONE: (916) 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) page: 3 of 3 PBS Front Line PRA Request 000139 STATS OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95533_____________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/26/2012 and conducted by Evaluator Susan Sadler COMPLAINT CONTROL NUMBER: 23-CR-20120926161325 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR:AUDRIE MEYER ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS; UNANNOUNCED MET WITH: Clinical Director, Audrie Meyer FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 10/04/2012 09:30 AM 12:30 PM ALLEGATION (S): Personal Rights Violation INVESTIGATION FINDINGS: 1 Complaint Specialist, Susan Sadler met with Clinical Director, Audrie Meyer to conduct Complaint Visit. CS 2 conducted staff and client file review and obtained documents. CS advised Agency further investigation is 3 required. 4 5 CS unabie to complete file review. CS will schedule a return visit. 6 7 8 9 10 11 12 13 Needs Further Investigation SUPERVISOR'S NAME: Leon Wells Estimated Days of Completion: TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Susan Sadler TELEPHONE: (916) 508-7748 LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/M) Page: 1 of 1 PBS Front Line PRA Request 000140 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional ORice, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833____ __________________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/24/2012 and conducted by Evaluator Staci Gorubec PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20120424135841 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: ANNOUNCED MET WITH: Wendi Counta, Associate Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 06/12/2012 04:00 PM 04:30 PM ALLEGATION(S): Personal Rights Violation INVESTIGATION FINDINGS: 1 Licensing Program Analyst, Staci Gorubec conducted an investigation regarding the above allegation, it was 2 reported that a staff member punched a resident 3 times and that this same staff had pulled this resident by his 3 shirt collar to lead him out of the gym. LPA reviewed staff and child files, interviewed child's social worker, the 4 program supervisor, two direct care staff and 4 children who reside in the house. 5 6 There is no evidence in staff file or in staff interviews to support the allegation is true. There is a piece of 7 contrary information obtained during the course of the investigation, therefore, although the allegation may 8 have happened, there is not a preponderance of evidence to substantiate the allegation. This finding is 9 INCONCLUSIVE. 10 11 12 13 inconclusive Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2012 This report must be available at Child Care and Group Home faciiities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000141 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/24/2012 and conducted by Evaluator Staci Gorubec CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20120424135841 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Marsha Lewis-Akyeem, Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 05/07/2012 12:30 PM 03:45 PM ALLEGATION(S): Personal Righls Violation INVESTIGATION FINDINGS: 1 Licensing Program Analyst, Staci Gorubec visited the facility for the purpose of conducting staff and children 2 interviews with regards to investigating a personal rights violation. 3 4 Further investigation is needed. 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Julie Darden TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Staci Gorubec TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) {06/04} Page: 1 of 1 PBS Front Line PRA Request 000142 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATQMAS PARK DRIVE SACRAMENTO, CA 95833____________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/19/2012 and conducted by Evaluator Dawn Eunice-MacLean COMPLAINT CONTROL NUMBER: 23-CR-20120319152428 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Marcia Lewis-Akyeem, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 03/28/2012 12:00 PM 04:00 PM ALLEGATION^): Resident's personal rights were violated Licensing Program Analysts Dawn Eunice-MacLean and Dora Hesia conducted the complaint visit to the above facility. LPA's reviewed a child's file. LPA's loured the grounds. LPA's interviewed staff and children. LPA's reviewed incident reports The personal rights issues addressed involved phone calls and mail. There are inconsistencies with information obtained during the course of the investigation. LPA's could not ascertain whether children's personal right to use the telephone and their personal right to send and receive unopened mail were violated. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to substantiate. The allegation is INCONCLUSIVE. LPA conducted exit interview, provided appeal rights, and delivered the findings on 3-28-12. Inconclusive SUPERVISOR'S NAME: Carol Hibbard LICENSING EVALUATOR NAME: Dawn Eunice-MacLean LICENSING EVALUATOR SIGNATURE; Estimated Days of Completion: TELEPHONE: (916) 263-4709 TELEPHONE: (916) 704-7366 DATE: 03/28/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1Of 1 PBS Front Line PRA Request 000143 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLO Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633______ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Collateral UNANNOUNCED MET WITH: Robert Dehn, HouseSupervisor FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 12/29/2011 10:15 AM 11:30 AM NARRATIVE 1 LPA Dawn Eunice-MacLean conducted a collateral visit purpose of interviewing a child regarding an incident 2 unrelated to this group home. This report is created to document this visit. 3 4 See LIC 812 and LIC 811 attached. 5 6 7 B 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunice-MacLean TELEPHONE: (916) 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2011 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) - (06/04) PBS Front Line PRA Request 000144 STATE OF CALIFORNIA - HEALTH AN HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2580 N. FIRST STREET, ST6, 350 SAN JOSE, CA95t31 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR; MARSHA LEWIS-AKYEEM ADDRESS : 2100 5THSTREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Collateral UNANNOUNCED MET WITH:______Courtney Gillain____________ FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 12/28/2011 10:30 AM 12:15 PM NARRATIVE 1 Today this worker made a collateral visit to Interview a client, referenced on Lie. #811, related to another 2 Licensed Care Facility. 3 4 Met with Facility Social Worker, Courtney Gillain. 5 6 This worker Faxed documents as EMQ/Families First Davis facility is monitored out of the Sacramento Office 7 and is not part of the San Jose database. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISORS NAME: Happy Stuart TELEPHONE: (650) 266-8829 LICENSING EVALUATOR NAME: Judith Brown TELEPHONE: (408) 406-2326 LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2011 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ^ W ; C. ^ This report must be available at Child Care and Group Home facilities for public review for 3 years. L1CB09 (FAS) - (06/04) PBS Front Line PRA Request 000145 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 96633 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Collateral UNANNOUNCED MET WITH: Laura Baillie, Director of School FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 09/26/2011 11:00 AM 12:00 PM NARRATIVE 1 Licensing Program Analyst Dawn Eunice-MacLean conducted a collateral visit to the above GH for the 2 purpose of interviewing a child. At LPA's arrival, the child at issue was at a dental appointment. LPA waited 3 for this child's return; the child was still gone, LPA will conduct the interview at a iater date. 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Dawn Eunice-MacLean TELEPHONE: (916) 704-7366 LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2011 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years, LIC809 (FAS) - (06/04) Page: 1 oi 1 PBS Front Line PRA Request 000146 STATE OF CALIFORNIA ~HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Case Management - Deficiencies UNANNOUNCED MET WITH: Wendi Conta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 05/19/2011 04:30 PM 05:30 PM NARRATIVE 1 Complaint Specialist Cindy Johnson arrived at the facility to provide corrected reports. When CS Johnson 2 concluded a complaint investigation on 5/4/11, civil penality for fingerprint clearance violation was inadvertenly 3 linked to the complaint #23-CR-20101230112534. 4 5 Staff files were reviewed on 1/10/11. It was discovered that Staff 1 presented a letter to the facility from CBCB 6 to the staff person granting an exemption. The facility neglected to complete, submit & wait for the transfer of the exemption to be approved before aliowing the staff to work. Staff 1 was hired on 5/18/09. This was pointed 8 out to Marsha Lewis-Akyeem & Wendy Counta on 1/10/11. Due to this being the first occasion, the facility 9 was assessed $500.00 civil penalties. 10 11 Prior to this facility visit, the matter has been resolved with CBCB and Staff 1 has the appropriate clearances 12 & assoications. 13 14 On 5/4/11, the facility was accurately assessed the correct amount of civil penalties for this violation. In this 15 case, the previous reprot is not able to be separated and re-linked to another report, so CS Johnson was 16 directed to created new reports. The previous civil penalties report dated on 5/4/11 with not be submitted for 17 processing and the facility will not be charged twice. 18 19 The fingerprint citation & civil penalty reports completed today will be processed. 20 21 22 23 24 25 SUPERVISOR'S NAME: Morgan Gallardo TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Cindy Johnson TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2011 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. LIC809 (FAS) - (06/04) PBS Front Line PRA Request 000147 STATE OF CALSFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/30/2010 and conducted by Evaluator Cindy Johnson COMPLAINT CONTROL NUMBER: 23-CR-20101230112534 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Wendy Counta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 05/04/2011 04:00 PM 06:00 PM ALLEGATI ON(S): Allegation #1: PHYSICAL ABUSE/CORPORAL PUNISHMENT: Restraint resulted in multiple injuries. INVESTIGATION FINDINGS: 1 Complaint Specialist Cindy Johnson arrived at the facility to deliver findings regarding the above allegation. CS 2 Johnson completed the 10 day complaint visit on 1/6/11. Additional visit occurred on 1/10/11 for additional file 3 review. Staff files and file of the alleged victim were reviewed. Copies of documentation obtained. Investigator 4 Lori Rodriguez conducted interviews with staff, residents, and social worker. It was confirmed that the alleged 5 victim had redness after a restraint, but an injury or bruises were not confirmed. Due to inconsistent 6 statements, it is not possible to determine whether the allegation occurred nor is it possible to determine that 7 the allegations definitely did not occur. Therefore the above allegation is INCONCLUSIVE, at this time. 8 9 Exit interview conducted, Appeal Rights provided. 10 11 12 13 Inconclusive Estimated Days of Completion: SUPERVISOR'S NAME: Morgan Gallardo TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Cindy Johnson TELEPHONE; (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE; DATE: 05/04/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) - (06/04) Page: 1 0f 1 PBS Front Line PRA Request 000148 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______ This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/20/2010 and conducted by Evaiuator Zenobia Bradley PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20101020084304 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Marsha Lewis-Akyeem, Wendi Counts FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 04/21/2011 02:30 PM 03:45 PM ALLEGATION^): Staff violated child's personal rights. Licensing Program Analyst Zenobia Bradley conducted the investigation on the allegation of personal rights violations. It was reported that a client was placed in a quiet room on 10/14/10 at approximately 11:00 pm to approximately 7:30 am on 10/15/10, without a bed, food and water, and was denied the right to use the restroom. The investigation included interviews with client and staff, and evidence obtained from the facility. Staff admitted to keeping the client in the quiet room overnight, and denying the client the right to use the restroom when the client asked. Staff admitted to giving the client a pillow and blanket to use while in the quiet room, and when the client asked to use the restroom the staff gave client a bucket and told client to use it. Based on the interviews and evidence obtained we find the allegation of the staff violated child's personal rights Substantiated. See attached 9099 D for deficiencies cited. Exit interview conducted. Appeal rights given. ________________________________________ ________________________ Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Zenobia Bradley TELEPHONE: (916) 216-9879 LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ,t DATE: 04/21/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. L1C9099 (FAS) - (06/M) Page: 1 Of 3 PBS Front Line PRA Request 000149 Control Number 23-CR-20101020084304 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2526 NATOMAS PARK DRIVE SACRAMENTO, CA 96633________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 04/21/2011 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type B 05/20/2011 Section Cited 84064(f)(1) 1 84064(f)(1) Administrator Qualifications. 2 Administrators shall provide direction and 3 evaluation of a group home facility within the limits 4 of the functions and policies established by the 5 licensee. 6 Staff reported this is a reoccurring issue. 7 1 All staff received training on personal rights, use of 2 quiet room/isolation community care licensing 3 standards 84322.1, notification policies around 4 crisis incidents, code of coduct and ethics, 5 emergency intervention plan, child abuse reporting, 6 guidelines for items brought to campus, and 7 boundaries expectations and overview. Type B 05/20/2011 Section Cited 80022(h) Type B 05/20/2011 Section Cited 80063(a) 1 80022(h) Plan of Operation. 1 All staff received training on personal rights, use of 2 The facility shall operate in accordance with the 2 quiet room/isolation community care licensing 3 terms specified in the plan of operation and may be 3 standards 84322.1, notification policies around 4 cited for not doing so. 4 crisis incidents, code of coduct and ethics, 5 Facility staff is not operating in accordance with the 5 emergency intervention plan, child abuse reporting, 6 policies and procedures approved by CCL. 6 guidelines for items brought to campus, and 7 boundaries expectations and overview. 1 80063(a) Accountability. 2 The licensee, whether an individual or other entity, 3 is accountable for the general supervision of the 4 licensed facility, and for the establishment of 5 policies concerning its operation. 6 Staff reported this is a reoccurring issue. 1 Board of Directors will be notified regarding the 2 staff reporting there is a reoccurring issue of staff 3 not following agency policies and procedures 4 regarding the use of the quiet room and following 5 crisis intervention protocol. The Board minutes will 6 be provided to CCL by the POC due date. 7 11 22 33 44 55 66 77 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Zenobia Bradley TELEPHONE: (916) 216-9879 LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2011 LIC9099 (FAS) - (06/04) Page:2 of 3 PBS Front Line PRA Request 000150 Control Number 2 3 - C R - ii l2 ti8 4 M 4 STATE OF CALFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 04/21/2011 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 04/22/2011 Section Cited 84072(c) (13) Type A 04/22/2011 Section Cited 84072(c)(14) 1 B4072(c}{13) Personal Rights. Personal rights 1 Staff was placed on administrative leave, received 2 include dignity in personal relationships with staff 2 a high level formal written disciplinary action, 3 and other persons. 3 completed 4 hours of training in personal rights, 4 Client#1 was kept in the quiet room overnight, 4 placed on probationary status, and signed a written 5 given a pillow and blanket to sleep on the floor, and 5 understanding of personal rights and crisis clinical 6 a bucket to urinate in. 6 contact protocol. 77 1 84072(c){14) Personal Rights. Personal rights 1 Staff was placed on administrative leave, received 2 include the right to live in a safe, healthy, and 2 a high level formal written disciplinary action, 3 comfortable home where he or she is treated with 3 completed 4 hours of training in personal rights, 4 respect. 4 placed on probationary status, and signed a written 5 Staff#1 and Staff#2 kept Client #1 in the quiet room 5 understanding of personal rights and crisis clinical 6 overnight. Staff gave client a pillow and blanket to 6 contact protocol. 7 sleep on the floor. Staff#2 denied client 7 8 the right to use the restroom, and gave client a 9 bucket to urinate in. 10 11 12 13 14 8 9 10 11 12 13 14 Type A 04/22/2011 Section Cited 84072{c){15) 1 84072(c) (15) Personal Rights, Personal rights 2 include the right to be free from physical sexual, 3 emotional, or other abuse, and corporal 4 punishment. 5 Staff#1 and Staff #2 emotionally abused Client #1 6 by keeping client in the quiet room overnight, with 7 pillow and blanket to sleep on the floor, and Staff #2 giving the client a bucket to urinate in. Staff was placed on administrative leave, received a high level formal written disciplinary action, completed 4 hours of training in personal rights, placed on probationary status, and signed a written understanding of personal rights and crisis clinical contact protocol. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment, SUPERVISOR'S NAME: Leon Wells TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Zenobia Bradley TELEPHONE: (916) 216 9879 LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2011 PBS Front Line PRA Request 000151 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633_______________________ This is an official report of an unannounced visit/rnvestigation of a complaint received in our office on 10/20/2010 and conducted by Evaluator Zenobia Bradley CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20101020084304 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: ANNOUNCED MET WITH: Wendi Counta, Associate Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 04/13/2011 09:00 AM 03:15 PM ALLEGATION(S): Staff violated chi Ids personal rights. INVESTIGATION FINDINGS: 1 Licensing Program Analyst Zenobia Bradley conducted interviews with staff and gathered documents. 2 Further investigation is needed. 3 4 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Leon Weils TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Zenobia Bradley TELEPHONE: (916) 216-9879 LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years, LIC9099 (FAS) - (06/M) Page: 1 of Z PBS Front Line PRA Request 000152 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/23/2011 and conducted by Evaluator Ashley Sinclaire CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20110323152533 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2 1 0 0 5THSTREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Marsha Lewis-Akyeem FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 03/24/2011 11:15 AM 01:30 PM ALLEGATION (S): Medication-Facility ran out of residents medication. Personal Rights-Resident's personal rights were violated. INVESTIGATION FINDINGS: 1 Needs Further Investigation 2 3 LPA, Ashley Sinclaire made an unannounced visit to the facility today to open the complaint. Files were 4 reviewed, documents obtained and an interview was conducted with the Administrator. 5 6 7 8 9 10 11 12 13 Needs Further investigation Estimated Days of Completion: SUPERVISOR'S NAME: Morgan Gallardo TELEPHONE: (916) 263-4809 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 fFAS) - {06/04) Page; 1 of 1 PBS Front Line PRA Request 000153 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, C A 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/30/2010 and conducted by Evaiuator Cindy Johnson COMPLAINT CONTROL NUMBER: 23-CR-20101230112534 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Marsha Lewis-Akyeem & Wendy Counta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 01/ 10/2011 12:30 PM 06:15 PM ALLEGATION (S): PERSONAL RIGHTS INVESTIGATION FINDINGS: 1 Complaint Specialist Cindy Johnson arrived at the facility to review staff files that weren't available at the end of 2 the last visit. 3 4 5 Further Investigation needed. 6 7 8 9 10 11 12 13 Needs Further investigation Estimated Days of Completion: SUPERVISOR'S NAME: Michele Wong TELEPHONE: (916) 263-4744 LICENSING EVALUATOR NAME: Cindy Johnson TELEPHONE: (916) 216-9877 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. L.IC9099 (FAS) - (06/04) Page: 1 011 PBS Front Line PRA Request 000154 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_____________ _______ This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/30/2010 and conducted by Evaluator Cindy Johnson COMPLAINT CONTROL NUMBER: 23-CR-20101230112534 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWIS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Marsha Lewis-Akyeem & Wendy Counta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 {530} 753-0220 95618 01/06/2011 03:00 PM 06:00 PM ALLEGATION (S): PERSONAL RIGHTS INVESTIGATION FINDINGS: 1 Complaint Specialist Cindy Johnson arrived at the facility to conduct a 10 day complaint visit and a file review. 2 Facility was informed that Investigation's Branch has assigned Investigator Crystal Lowe to conduct the 3 investigation. Staff schedule has been obtained. Roster of residents assigned to Pioneer House was obtained. 4 5 6 Further investigation needed 8 9 10 11 12 13 Needs Further Investigation SUPERVISOR'S NAME: Michele Wong LICENSING EVALUATOR NAME: Cindy Johnson LICENSING EVALUATOR SIGNATURE: Estimated Days of Completion: TELEPHONE: (916) 263-4744 TELEPHONE: (916) 216-9877 DATE: 01/06/2011 A I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: "3 DATE: 01/06/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9089 (FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000155 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_______________________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/02/2010 and conducted by Evaluator Ashley Sinclalre PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20101102154700 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: MARSHA LEWiS-AKYEEM ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 CENSUS: UNANNOUNCED MET WITH: Wendi Counta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 11/09/2010 12:00 PM 02:15 PM ALLEGATION(S): Personal Rights- Staff used inappropriate language with resident. INVESTIGATION FINDINGS: 1 SUBSTANTIATED 2 3 LPA, Ashley Sinclaire made a visit to the facility today to open the complaint. Files were reviewed and an 4 interview conducted with Associate Director, Wendy Counta. It was determined that the staff member had used 5 inappropriate language with the resident. The staff person has received a warning that has been placed in his 6 employee file. A corrective action was put in place calling for the staff person to attend a training related to the 7 expectations of conduct related to the agency's program. In addition, he is required to attend regular 8 supervision meetings to discuss his interventions with children. 9 10 11 12 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Vincent Herrera TELEPHONE: (916) 263-4708 LICENSING EVALUATOR NAME: Ashley Sinclaire TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2010 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2010 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 3 PBS Front Line PRA Request 000156 Contro! Number 23-CR-2011102154:7D STATE OF CALIFORNIA - HEALTH ANO HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33___________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 11/09/2010 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 12/09/2010 Section Cited 84072(c)13 1 Personal Rights-Each child shall be accorded ! dignity and respect in his personal relationships 3 with staff. 4 5 -Staff used inappropriate language with resident. 6 7 1 The facility will provide training in Title 22 y regulations regarding personal rights. Proof of 3 training will be sent to CCL. 4 5 6 7 11 22 33 44 55 66 77 11 22 33 44 55 66 77 11 22 33 44 55 66 77 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Vincent Herrera TELEPHONE: (916) 263-4708 LICENSING EVALUATOR NAME; Ashley Sinclaire TELEPHONE: (916) 838-8919 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2010 i acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2010 LIC9099 (FAS) - (06/04) Page: 2 of 3 PBS Front Line PRA Request 000157 STATS OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/20/2010 and conducted by Evaluator Zenobia Bradley CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-201010200B4304 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 72 : CENSUS: UNANNOUNCED MET WITH: Marsha Lewis-Akyeem FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 11/01/2010 01:55 PM 03:00 PM ALLEGATI ON(S): Staff violated childs personal rights. INVESTIGATION FINDINGS: 1 Licensing Program Analyst Zenobia Bradley conducted the 10 day visit at the facility. 2 LPA met with Marsha Lewis-Akyeem, Services Director and Wendi Counts, Program Manager regarding the 3 allegations. LPA obtained contact information for witnesses and staff involved in the allegation. 4 5 Advised further investigation is needed. 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: SUPERVISOR'S NAME: Vincent Herrera TELEPHONE: {916} 263-4708 LICENSING EVALUATOR NAME: Zenobia Bradley TELEPHONE: (916) 216-9879 LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2010 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: Signature en paper copy in file DATE: 11/01/2010 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page; 1 of 2 PBS Front Line PRA Request 000158 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95533 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 72 CENSUS: TYPE OF VISIT: Collateral UNANNOUNCED MET WITH: Client/Chiidcare Worker FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95618 08/26/2010 10:15 AM 11:45 AM NARRATIVE 1 LPA, Ashley Sinclaire made an unannounced visit to the facility today to interview a client regarding an 2 incident that happened at another facility. 3 4 5 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Vincent Herrera LICENSING EVALUATOR NAME: Ashley Sinclaire LICENSING EVALUATOR SIGNATURE: TELEPHONE: (916) 263-4708 TELEPHONE: (916) 838-8919 DATE: 08/26/2010 /A l 1acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2010 l (M lk This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04) Page: 1 o f 1 PBS Front Line PRA Request 000159 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 63 CENSUS: TYPE OF VISIT: Case Management - Other ANNOUNCED MET WITH:_____ Marsha Lewis-Akyeem, Administrator FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530} 753-0220 95618 06/29/2010 09:20 AM 10:30 AM NARRATIVE 1 LPA Julie Darden conducted a case management visit on today's date for purposes of inspecting the facility 2 for a change of capacity request. Facility is currently licensed to serve 63 children. They are requesting a 3 capacity increase to 72. The facility is requesting that this capacity increase be completed in increments (66 4 to 69 to 72 every two months) for rate setting/staffing purposes. This was discussed with the director during 5 today's inspection. Facility may opt to request capacity increase to the maximum of 9 at this time based on 6 the discussion held. The facility has received a fire clearance for 72. 7 8 Inspection completed of housing section which will be used for placement of 9 girls, ages 6-15. There are 4 9 bedrooms with 2 beds each, and 1 bedroom with 1 bed. Appropriate bed and dresser space available. No 10 closets were observed. Facility has existed with bedrooms with no closets since licensure. This issue will be 11 discussed with supervisor to determine if waiver is required at this time. There is one quiet room that does 12 not have locks. Toxins/cleaning supplies are stored in locked laundry room. Facility is adequately furnished 13 and ail furniture observed to be in acceptable condition. No medication will be stored in facility. Bathroom 14 accommodations appear adequate and in good, sanitary condition. There is a separate staff office with the 15 ability to be locked and secured. Facility grounds were observed to be in excellent condition. 16 17 The capacity increase is recommended for approval at this time, pending submission of Board Resolution (to 18 be submitted via FAX by COB today). Facility will contact LPA Darden no later than COB on 6/29/10 if they 19 want to continue to increase capacity in increments as described above. Graduated capacity increases will 20 require the submission of applications and appropriate fees. Additional inspections will also be required prior 21 to approval of future capacity increases. 22 23 24 25 SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Julie Darden TELEPHONE: (916) 704-7085 LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2010 I acknowledge receipt of this form and understand my censing 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. LIC809 (FAS! - {06/04) Page: 1 of 1 PBS Front Line PRA Request 000160 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO, CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA S5833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 02/03/2009 and conducted by Evaluator Janet Dupzyk CONFIDENTIAL COMPLAINT CONTROL NUMBER: 23-CR-20090203154233 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 63 CENSUS: UNANNOUNCED MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 04/22/2009 04:02 PM 04:30 PM ALLEGATI ON(S): PERSONAL RIGHTS: Child #1 had bruise larger than a quarter on right shoulder from restraint. NEGLECT/LACK OF CARE: Child #1 went on a visit having no shirt under a coat, no socks, and no underwear and child was cold. THIS IS AN AMENDED REPORT OF LIC 9099 DATED 3/12/2009 SUBSEQUENT TO AN APPEAL FROM THE FACILITY ON 3/23/2009. LPA Helot conducted interviews with complainant, group home staff along with a review of documents obtained during 2/12/09 visit and follow up information submitted by Associate Director to CCL on 2/24/09. Information from these interviews and document review reveals Child #1 sustained injuries during a restraint. The 2/24/09 follow up reflects Senior trainer will provide additional guidance during restraints to ensure proper holds. The 2/24/09 follow up indicates team members have already addressed the situation where Child #1 was sent on a visit without a shirt, socks and underwear and have devised a plan to double check Child #1 prior to his visits away from the facility. The 2/24/09 follow up stated Child #1 was voluntarily discharged from the program on 2/20/09. Therefore the following violations under the California Code of Regulations, Title 22, Division 6 Chapter 5 are cited on attached page. A COPY OF THIS REPORT WAS FAXED TO THE FACILITY ON 4/22/09. PLEASE REVIEW, SIGN, DATE AND RETURN A COPY TO CCL. Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Mary Joils TELEPHONE: (916) 263-4810 LICENSING EVALUATOR NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC909B (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000161 Control Number 23-CR-20090203154233 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833_________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE- 04/22/2009 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 04/12/2009 Section Cited 80087 (A)(1)-(3) 1 PERSONAL RIGHTS 1 Administrator to submit a plan of correction to 2 During a restrain, staff caused an injury to Child #1 2 Commnlty Care Licensing by APRIL 12, 2009. 33 f\ 4 55 66 77 Type B 04/12/2009 Section Cited 80078(a) 1 RESPONSIBILITY FOR PROVIDING CARE AND 2 SUPERVISION 3 Staff failed toproperiy monitor Child #1 prior to a 4 home visit and child left the facility without a shirt, 5 socks and underwear. 6 7 1 Administrator to submit a plan of correction to 2 Community Care Licensing by APRIL 12, 2009. 3 4 5 6 7 11 22 33 44 55 66 77 11 22 33 44 55 66 77 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Mary Jolis TELEPHONE: (916) 263-4810 LICENSING EVALUATOR NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2009 UC9099 (FAS) - (06/04) Page: 2 of 2 PBS Front Line PRA Request 000162 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95633________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 02/03/2009 and conducted by Evaluator Mary Helot PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20090203154233 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 63 CENSUS: UNANNOUNCED MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 03/12/2009 05:56 PM 05:57 PM ALLEGATION (S): PERSONAL RIGHTS: Child #1 had bruise, larger than a quarter on right shoulder from restraint. NEGLECT/ LACK OF CARE: Child #1 went on a visit having no shirt under a coat, no socks, and no underwear and child was cold, MEDICATION: The authorized representative was informed in the past of medication changes, however was not informed of recent changes, nor provided authorization for the change. see attached (LIC 811) for confidential names LPA Helot conducted interviews with complainant, group home staff along with a review of documents obtained during 2/13/09 visit and follow up information submitted by Associate Director to CCL on 2/24/09. Information from these interviews and document review reveals Child #1 sustained injuries during a restraint, The 2/24/09 follow up reflects Senior trainer will provide additional guidance during restraints to ensure proper holds. The 2/24/09 follow up indicates team members have already addressed the situation where Child #1 was sent on a visit without a shirt,socks and underwear and have devised a plan to double check Child #1 prior to his visits away from the facility. Furthermore, the 2/24/09 follow up confirms authorized representative was not informed of the recent changes to Child #1's medication nor provided authorization for the change. The 2/24/09 follow up stated Child #1 was voluntarily discharged from the program on 2/20/09. Therefore the following violations under the California Code of Regulations, Title 22, Division 6 Chapter 5 is cited on attached page. Substantiated SUPERVISOR'S NAME: Janet Dupzyk LICENSING EVALUATOR NAME: Mary Helot LICENSING EVALUATOR SIGNATURE: Estimated Days of Completion: TELEPHONE: (916) 263-4700 TELEPHONE: (916) 704-8702 DATE: 03/12/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 'A 0 O f DATE: 03/12/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) Page: 1 of 2 PBS Front Line PRA Request 000163 Contro! Number 23-CR-20090203154233 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95553___________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE: 03/12/2009 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTlONS(POCs) Type A 04/12/2009 Section Cited 80072(a)(1)-(3) 1 SECTION 80072(a)(1)-(3)- PERSONAL RIGHTS, 2 During a restraint, staff caused an injury to Child 3 #1, 4 5 6 7 1 Administrator to sumbit a plan of correction to 2 Community Care Licensing by APRIL 12, 2009. 3 4 5 6 7 Type B 04/12/2009 Section Cited 80078(a) 1 SECTION 80078(a)- RESPONSIBILITY FOR 1 Administrator to sumbit a plan of correction to 2 PROVIDING CARE AND SUPERVISION. 2 Community Care Licensing by APRIL 12, 2009. 3 Staff failed to properly monitor Child #1 prior to a 3 4 home visit and left the facility without a shirt, socks 5 and underwear. 6 5 6 7 Type B 04/12/2009 Section Cited 84068.3(b)(1) 1 SECTION 84068.3(b)(1)-MODIFICATIONS TO 2 NEEDS AND SERVICES PLAN. 3 Staff did not inform authorized representative of 4 recent changes nor obtain authorization for Child 5 #Ts medication. 6 7 1 Administrator to sumbit a plan of correction to 2 Community Care Licensing by APRIL 12, 2009. 3 4 5 6 7 11 22 33 44 55 66 77 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civii penalty assessment. SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2009 i acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: K cv `4 . C i f Y DATE: 03/12/2009 LIC999 (FAS* - (06/04) Page: 2 of 2 PBS Front Line PRA Request 000164 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO, CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95S33 This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/27/2009 and conducted by Evaluator Mary Helot PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-20090127083955 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 63 CENSUS: UNANNOUNCED MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 03/12/2009 02:19 PM 02:20 PM ALLEGATION (S): NEGLECT/LACK OF SUPERVISION: Resident's head and back injured during the restraint, but medical attention was not sought. INVESTIGATION FINDINGS: 1 LPA Helot conducted interviews with staff along with records review . Although the allegations may have 2 happened or is valid, information from these interviews cannot produce a preponderance of the evidence to 3 prove the allegation occurred. 4 5 Therefore allegation is inconclusive at this time. 6 7 8 9 10 11 12 13 inconclusive Estimated Days of Completion: SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 2 hcVcA 05 p DATE: 03/12/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS} - (06/04} Page; 1 of 2 PBS Front Line PRA Request 000165 Control Number 23-CR-2D09022O839&S STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 577000449 VISIT DATE- 03/12/2009 Deficiency Type POC Due Date / Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 04/12/2009 Section Cited 84300(b)(1) 1 SECTION 843009(b)(1 GENERAL PROVISIONS, 2 Staff used a restraint on Child #1 who did not 3 exhibit behaviors that were endangering himself, 4 or others, This child had thrown clothes and 5 squirted conditioner on a staff member prior to the 6 prone restraint 7 1 Administrator will submit a plan of correction to 2 CCL by APRIL 12, 2009, 3 4 5 6 7 Type B 04/12/2009 Section Cited 84361 (a) 1 SECTION 84361 - DOCUMENTATION AND 2 REPORTING REQUIREMENTS. 3 CCL nor Child # l's authorized representative 4 received i information on restraint in a timely 5 manner. 6 7 1 2 3 4 5 6 7 1 Administrator will submit a plan of correction to 2 CCL by APRIL 12, 2009. 3 4 5 6 7 1 2 3 4 5 6 7 11 22 33 44 55 66 77 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2009 LIC999 (FAS) - (06/04} Page: 2 of 2 PBS Front Line PRA Request 000166 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95B33_________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/27/2009 and conducted by Evaluator Mary Helot PUBLIC COMPLAINT CONTROL NUMBER: 23-CR-2009G127083955 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 63 CENSUS: UNANNOUNCED MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 03/12/2009 02:19 PM 02:20 PM ALLEGATION^): 1 ' PERSONAL RIGHTS: Resident improperly restrained, was hurt in the course of the restraint (1/23/09). 2 3 OTHER: Restraint/injury was not reported to the authorized representative or the licensing agency, 4 5 see attached (LIC 811) for confidential name 6 7 8 9 INVESTIGATION FINDINGS: 1 Licensing Program Analyst(LPA) Mary Helot conducted interviews with staff along with a review of documents 2 obtained from Child #Vs file during 1/29/09 inspection. Information from these interviews and file review 3 reveals staff improperly restrained Child #1, the circumstances prior to the restraint were unjustified and 4 information did not establish Child #1 was a danger to himself or others. It was also confirmed neither 5 Community Care Licensing (CCL) nor the Child #1 's County Social worker were notified in a timely manner of 6 such restraint. 7 8 Therefore allegations are substantiated and the foilowing violation under the California Code of Regulations, 9 Title 22, Division 6 Chapter 5 is cited on attached page. 10 11 12 13 Substantiated SUPERVISOR'S NAME: Janet Dupzyk Estimated Days of Completion: TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: M . W k C4 f v DATE: 03/12/2009 This report must be available at Child Care and Group Home facilities for pubiic review for 3 years. LSC9099 (FAS} - (06/04) Page: 1 Of 2 PBS Front Line PRA Request 000167 STATE OF CAUFORNJA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833 This is an official report of an unannounced visit/investigation of a complaint received in our office on 02/03/2009 and conducted by Evaluator Mary Helot COMPLAINT CONTROL NUMBER: 23-CR-20090203154233 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CAPACITY: 63 CENSUS: UNANNOUNCED MET WITH: Wendi Counta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 02/13/2009 01:15 PM 02:29 PM ALLEGATION(S) : PERSONAL RIGHTS: Child #1 had bruise, larger than a quarter on right shoulder from restraint. NEGLECT/ LACK OF CARE: Child #1 went on a visit having no shirt under a coat, no socks, and no underwear and child was cold. MEDICATION: The authorized representative was informed in the past of medication changes, however was not Informed of recent changes, nor provided authorization for the change. OTHER: Group home has not complied with their own plan of operation and emergency intervention plan. INVESTIGATION FINDINGS: 1 Licensing Program Analyst(LPA) Mary Helot met with Program Manager Wendi Counta, Social Worker 2 Natasha Bibayoff and were informed of above allegations. 3 4 Copies of pertinent documents from child's file were obtained. Addtional information is required at this time. 5 6 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: 90 Days SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2009 ! acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 {FAS) - (06/04) Page: 1 of 1 PBS Front Line PRA Request 000168 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CAL CR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 9SB33______________________ FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: 2100 5TH STREET CITY: DAVIS STATE: CA CAPACITY: 63 CENSUS: TYPE OF VISIT: Case Management * Incident UNANNOUNCED MET WITH: Wendi Counta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 02/13/2009 01:15 PM 02:29 PM NARRATIVE 1 Purpose of inspection today is to discuss Incident Report (IR) dated 1/17/09 involving Staff restraining Child 2 #1. The iR states the events leading up to restraint were child was frustrated because he wanted to suggest 3 an activity outside when staff already established an activity and child went running outside. The child was 4 later placed in the Quiet Room and while in this area, staff transitioned to a wall assisted containment. 5 6 It appears restraint was not justified, Administrator will submit additional information explaining reason 7 restraint was used with this child to Community Care Licensing by FEBRUARY 23, 2009. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2009 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) - (06/0A) Page: 1 o< 1 PBS Front Line PRA Request 000169 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. CALCR/RES., 2525 NATOMAS PARK DRIVE SACRAMENTO, CA 95833______________________ This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/27/2009 and conducted by Evaluator Mary Helot COMPLAINT CONTROL NUMBER: 23-CR-20090127083955 FACILITY NAME: FAMILIES FIRST INC. PSYCHIATRIC TREATMENT ADMINISTRATOR: HEINTZ, LAURA ADDRESS: CITY: CAPACITY: 2100 5TH STREET DAVIS 54 STATE: CENSUS: UNANNOUNCED MET WITH: Wendy Conta FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 577000449 730 (530) 753-0220 95616 01/29/2009 02:30 PM 03:59 PM ALLEGATSON(S); PERSONAL RIGHTS: Resident improperly restrained, was hurt in the course of the restraint (1/23/09). NEGLECT/LACK OF SUPERVISION: Resident's head and back injured during the restraint, but medical attention was not sought. OTHER: Restraint/injury was not reported to the authorized representative or the licensing agency, see attached (LIC 811) for confidential name INVESTIGATION FINDINGS: 1 Licensing Program Analyst(LPA) Mary Helot met with Program Manager Wendy Conta, Campus Supervisor 2 Joel Lopez and were informed of above allegations. 3 4 Copies of pertinent documents from child's file were obtained. Addtional information is required at this time. 5 6 Investigation to continue. 7 8 9 10 11 12 13 Needs Further Investigation Estimated Days of Completion: 90 days SUPERVISOR'S NAME: Janet Dupzyk TELEPHONE: (916) 263-4700 LICENSING EVALUATOR NAME: Mary Helot TELEPHONE: (916) 704-8702 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: [j Qja^ U i W l f e DATE: 01/29/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04) PBS Front Line PRA Request 000170