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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367900008
Report Date: 08/15/2023
Date Signed: 08/16/2023 03:01:29 PM


Document Has Been Signed on 08/16/2023 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501



FACILITY NAME:MY PLACEFACILITY NUMBER:
367900008
ADMINISTRATOR:DARRYL EVEYFACILITY TYPE:
732
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 6DATE:
08/15/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darryl Evey, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On August 15, 2023, at 2:00 p.m., Licensing Program Analyst (LPA) Val Wilson, LPA Nicole Strickland, Licensing Program Manager (LPM) Jennifer Smith and Regional Manager (RM) LaCresha Cook met with Family Assistance Program (FAP) Chief Executive Officer (CEO) and My Place Administrator Darryl Evey, Chief Operating Officer (COO) Ken Weekes, My Place Shelter Manager Fatima Herrera, Our House Shelter Manager Joe Mendoza, Our House Social Worker Julie Ann Ferreira, Board Member John Perring-Mulligan, Board Member Kierre Coghill, CDSS System of Care (SOC) Provider Policy Implementation Unit Manager Alicia Bernstein, SOC Policy Analyst Chris Meyer, SOC Health Program Specialist I Hong Luu, SOC Policy Analyst Gina Jones, Child Trafficking Research and Policy Unit Analyst Leland Turner, Catalyst Center Senior Program Advisor Misty Berard and Kelsie Tatum Martinez, San Bernardino County Children and Family Services (SBCCFS) Shelter Coordinator Amy Mierzwi, SBCCFS Deputy Director Nancy Satterwhite, SBCCFS Assistant Director Jonathan Byers, SBCCFS PRD Tracy Raymond and SBCCFS PRD Ana del Nogal; Department of Behavioral Health (DBH) San Bernardino County Dianne Wolkenhauer, PhD, Department of Health Care Services Staff Services Manager Dave Gutierrez and Central Placement Unit Supervisor Christina Lopez via Microsoft Teams for a virtual informal office conference.

The purpose of the meeting was to discuss the following issues and concerns with the Licensee for both Our House and My Place facilities: Administrator qualifications and duties, lack of administrative oversight, staff training, plan of correction, lack of trauma informed care, personal rights, and lack of supervision concerning the Our House facility. The three areas of concern applicable to the My Place facility are lack of administrative oversight, Administrator qualifications and duties and Plan of correction.



Administrator qualifications and duties - LPM Smith advised there are concerns regarding the Administrator’s lack of knowledge regarding specific incidents that have occur in the facility, lack of knowledge of the clients in care and the needs and services of the clients in care, and Administrator referring
(Continued on page 2)
SUPERVISOR'S NAME: Jennifer SmithTELEPHONE: (951) 320-2029
LICENSING EVALUATOR NAME: Valerie WilsonTELEPHONE: 951-897-9155
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME: MY PLACE
FACILITY NUMBER: 367900008
VISIT DATE: 08/15/2023
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Pg 2 (Continued from page 1)
Community Care Licensing (CCL) representatives to the Facility Manager, Joe Mendoza for information. The concerns cover the period of February 2022, when the Administrator of Our House was Darryl Evey until present. CEO stated that they are in the process of having facility administrators present at the facilities for 40 hours per week. They are also in the process of hiring a Director that will be overseeing the Administrators.

Lack of oversight- LPM Smith advised there are concerns that the Administrator is not familiar with the regulations and there is a breakdown in communication amongst the staff. RM Cook stated there should be oversight by the Administrator and Board of Directors for all facility operations. CEO stated reports are emailed to CEO and he works on the outcome. Each month there is a board meeting and they go over special incident reports and Licensing reports. They also have a leadership meeting each week to go over pending issues. SBCCFS PRD Tracy Raymond shared improvements observed with Our House since the implementation of new youth and shelter protocols that San Bernardino county provides assist with, including CFTMs being initiated immediately, internal meetings every other week with FAP. The addition of Social Worker Julie Ann who comes from a trauma informed focus has been a strong positive influence over the last year. There are also supportive actions like peer advocates meeting with the youth to assist youth to adjust to being in a shelter. Tracy reported that Our House accepts placement for a broad spectrum of youth that are difficult to place and STRTP’s are no longer willing to work with. If FAP calls the county emergency hotline, San Bernardino county representatives report to the facility and remove youth as necessary from placement to assist with de-escalation of emergency situations and crisis intervention. Tracy stated San Bernardino county is improving their practice and are helping FAP improve in their operations, working together as a partnership.

Staff training- RM Cook advised there are concerns regarding a lack of staff training being reported from information gathered during complaint investigations and the annual inspections. CEO stated they began documenting the ongoing training a year ago when CCL brought this to their attention. Staff training is done every other Thursday, debriefing is done during staff meetings, along with scheduling staff, and outside agency training is provided. The process to onboard is four months and staff turnover averages at four months, leaving continued staffing issues as a primary struggle. As an incentive, the benefit of a half-paid day off has been implemented and additionally there are more outdoor activities which help the staff’s mental health. (Continued to page 3)
SUPERVISOR'S NAME: Jennifer SmithTELEPHONE: (951) 320-2029
LICENSING EVALUATOR NAME: Valerie WilsonTELEPHONE: 951-897-9155
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME: MY PLACE
FACILITY NUMBER: 367900008
VISIT DATE: 08/15/2023
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Representative from the Catalyst Center, Misty Berard shared they are available for support and shared the following links: mberard@catalyst-center.org; kmartinez@catalyst-center.org; https://catalyst-center.teachable.com/courses;
https://catalystcenter.learnupon.com/store

Plan of correction (POC)- LPM Smith advised that Joe from Our House and Fatima of My Place submit plan of corrections in a timely manner. There are concerns with the plan of correction from Nike of My Place and Devin of Our House not being submitted on time and verbally stating the plan of correction will be late. LPA Valerie Wilson has reminded them that the request for an extension for the plan of correction needs to be submitted and approved by CCL prior to the due date. LPM Smith advised if plan of correction is not received by the due date and there has not been an extension approved by CCL for the plan of correction due date the facility can be assessed civil penalties. CEO stated that Fatima's Administrator qualifications were turned in to CCL for My Place. Fatima will ensure that the plan of corrections are done properly. The current Administrator for Our House, Devin, will be separating employment from Our House at the end of the month and a new Administrator will be hired at Our House. The Board has done some interviews to fill the Administrator position. CEO complained that previous administrator packets took longs periods of time to approve and possibly Joe Mendoza can be designated during CCL's review of the administrator packet. RM Cook stated that the turnaround time for administrator qualifications review should be less than two weeks if the statement of qualification, and the correct documents are all provided in a timely manner to the LPA, and the candidate meets regulation requirements. If additional information is needed from the facility the turnaround time may be longer.

Lack of trauma informed care- RM Cook advised that there have been substantiated complaints and case managements involving violations of personal rights that imply a lack of trauma informed care being provided by the facility staff. CEO stated their staff receive a lot of harm reduction and trauma informed care trainings. SOC Alicia Bernstein provided an overview of trauma informed care and provide resources. Child Trafficking Research and Policy Unit Analyst Leland Turner discussed harm reduction and provided resources and links for support. leeland.turner@dss.ca.gov (Continued to page 4)
SUPERVISOR'S NAME: Jennifer SmithTELEPHONE: (951) 320-2029
LICENSING EVALUATOR NAME: Valerie WilsonTELEPHONE: 951-897-9155
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME: MY PLACE
FACILITY NUMBER: 367900008
VISIT DATE: 08/15/2023
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https://www.cdss.ca.gov/Portals/9/ACIN/2019/I-28_19.pdf?ver=2019-07-23-145815-020, ACIN I-28-19 (July 22, 2019) Harm Reduction Series - Social Worker, ACIN I-50-19 (July 29, 2019) Harm Reduction Series - Probation Officer, ACIN I-36-21 (June 22, 2021) Harm Reduction Series – Law Enforcement, ACIN I- 31-22 (April 8, 2022), Harm Reduction Series – Caregiver and ACIN I-59-18 (September 14, 2018) Introduction to the Harm Reduction Strategies Series Regarding Commercially Sexually Exploited Children.

Personal rights and Lack of supervision– LPM Smith discussed several substantiated complaints regarding personal rights and lack of supervision from 2022 to present. LPM Smith summarized deficiencies cited. LPM Smith informed the Licensee of the Technical Support Program (TSP), stating it is a branch that can work with FAP in various areas they may need support in regarding facility operations. A referral can be made but it is voluntary. CEO stated their intention was never to work with foster youth, but there was a need and CFS asked the facility for support. CEO stated foster youth are much more difficult than the runaways and respond differently to the support, and support with crisis intervention would be appreciated. LPM Smith advised FAP to identify any areas they may need support to CCL and CCL will submit a TSP referral. Tracy Raymond stated the harm reduction training and resources provided by the Child Trafficking Research and Policy Unit is super informative for harm reduction and collaboration. Tracy also stated that San Bernardino county understands the responsibility they have in this situation and will continue to partner with the facility to help with compliance issues. CEO stated that he was not in agreement with CCL findings. RM Cook advised that FAP has the right to appeal and there are times the appeal is heard and findings are overturned. SBCCFS Deputy Director Nancy Satterwhite stated the county has looked at ways to collaborate and how to "team" placement combinations for youth in care. Peer family advocates are connected with the youth and it has been beneficial. San Bernardino county will also be hosting a mandated reporter training at Our House and looking at the contracts with the County for extra supports services that can be implemented. The CEO reported feeling better about the interaction with DCFS and how they are removing the clients to help the Program succeed along with the new contract that includes a new crisis intervention protocol. RM Cook reminded that regulatory enforcement and compliance is provided to protect the health and safety of youth in care and CCL hopes that the Licensee will take advantage of the assistance, collaboration, and all resources offered and provided by CCL and each department represented in the meeting.
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SUPERVISOR'S NAME: Jennifer SmithTELEPHONE: (951) 320-2029
LICENSING EVALUATOR NAME: Valerie WilsonTELEPHONE: 951-897-9155
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME: MY PLACE
FACILITY NUMBER: 367900008
VISIT DATE: 08/15/2023
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The licensee is being requested to submit a Plan of Action for each of the focus areas above including the following:
- How will the Board of Directors ensure appropriate administrative oversight is implemented?
- Submit an updated LIC 500 for the hours that will be worked by the Administrator and facility staff
-How will the Board review complaints, what information will be included in board meeting minutes, and how will the Board address issue client health and safety issues as they arise?
- How will the facility ensure staff training is completed.
- How will the facility ensure staff have knowledge of the program statement?
- How will the facility ensure staff know how to implement appropriate crisis intervention?
- How will the facility ensure the plan of corrections are completed and submitted to CCL by the due date?
- How will the facility ensure trauma informed care is being provided?
- How will the facility ensure the personal rights of clients are not being violated by staff?
- How will the facility ensure that staff are adequately supervising the clients?

The Plan of Action response will be submitted to CCL by August 29, 2023. If more time is needed to submit the plan of action or there are any questions, please contact LPA Valerie Wilson at
valerie.wilson@dss.ca.gov or (951) 897-9155.

A copy of this report was emailed to CEO Darryl Evey for electronic signature. The signed report will be placed in the facility file.
SUPERVISOR'S NAME: Jennifer SmithTELEPHONE: (951) 320-2029
LICENSING EVALUATOR NAME: Valerie WilsonTELEPHONE: 951-897-9155
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5