425800215-8-23-2024-29-AS-BPHS-D8EPH5-20240823111922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800215
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:19:43 AM

Document Has Been Signed on 08/23/2024 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MCMILLAN RANCH		FACILITY NUMBER:	425800215
ADMINISTRATOR/ DIRECTOR:	MARTHA MANCHA		FACILITY TYPE:	735
ADDRESS:	3840 ORCUTT GAREY ROAD		TELEPHONE:	(805) 937-2826
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY: 10		CENSUS: 9	DATE:	08/23/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Martha Mancha, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent case management-incident investigation visit to deliver final findings for the allegation Neglect/Lack of Care and Supervision. During today’s visit, LPA Phillips met with Administrator Martha Mancha and explained the reason for the visit. On 03/18/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding client #1 (C1) alleging that they were sexually assaulted on 03/09/2024, by an individual (name not included on UIR). The UIR noted that on 03/09/2024, at approximately 9:30am, facility Staff were approached by C1 stating that they were experiencing back pain and bleeding. Around 1:25pm, C1 stated that they were raped. C1 showed staff their underwear they wore which C1 claimed had semen on the crotch area. The Case Management-Incident investigation was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. It was determined that a full investigation of Neglect/Lack of Care and Supervision that led to sexual abuse is warranted. On 04/08/2024, the assignment was upgraded to a full IB investigation. On 03/19/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct a Case Management-Incident visit. LPA Phillips met with Administrator Martha Mancha, Residential Counselor Mary Ellen, and announced the purpose of the visit. The LPA conducted a physical tour, requested documents, LPA observed the facility, resident bedrooms, and common areas (kitchen, dining room, living room, bathrooms). The LPA determined further investigation was needed prior to issuing findings. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCMILLAN RANCH	FACILITY NUMBER: 425800215
	VISIT DATE: 08/23/2024

NARRATIVE

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Investigator Santiago conducted interviews on 04/05/2024, at approximately 7:49am, with facility Residential Counselor #1; on 04/05/2024, at approximately 8:10am, with facility Administrator/Program Manager; on 04/05/2024, at approximately 8:25am, with facility Residential Counselor #2; on 04/05/2024, at approximately 8:40am, with facility Client #2 (C2)/Potential Witness; on 04/05/2024, at approximately 9:20am, with facility Client #1 (C1)/Victim; on 06/13/2024, at approximately 12:50pm, with Facility Client #3 (C3)/Potential Witness; on 06/13/2024, at approximately 1:05pm, with Facility Client #4 (C4)/Alleged Perpetrator; on 07/10/2024, at approximately 12:05pm, with facility Residential Counselor #3; on 07/10/2024, at approximately 12:58pm, with facility Residential Counselor #4; and on 07/10/2024, at approximately 1:40pm, with former facility client/potential witness. In addition, the investigator reviewed medical records from Marian Regional Medical Center, police report from Santa Barbara County Sheriff Department, and facility file documents related to C1.

C1 maintained during their interview with IB investigator Santiago, law enforcement and facility staff that they were “raped” when they woke up in the early morning hours on 03/09/24. C1 reported having symptoms that they associated to being sexually assaulted. C1 identified that C4 “raped” them but could not clearly articulate how they were raped by C4 as they did not recall seeing C4 on them and denied feeling any penetration. C1 identified the only proof they had of C4 being a perpetrator was the “brown semen” they found on their underwear. C1’s roommate was interviewed, but due to their mental health condition, could not provide any corroborating statements. C4’s roommate also denied that they witnessed C4 commit any inappropriate, romantic, or sexual conduct toward C1. C4 refuted the claim that they sexually assaulted C1. A facility staff that worked nocturnal shift on 03/09/2024 reported that they checked all clients every hour and did not observe any suspicious activities between them. A Sexual Assault Response Team (SART) exam was completed on C1 and did not reveal any evidence of DNA. Furthermore, records and interviews revealed that C1 presented symptoms of delusions; C1 also reported that they received “messages in her head” from “Technology” warning them that they were going to get “raped by C4” days prior to the alleged incident.

California Mental Health Services Authority (CalMHSA) Santa Barbara County Progress Notes for C1 indicate that on 03/13/2024, it was noted that around evening time, C1’s behavior was inappropriate towards one of their peers yelling, “they raped me” in front of their peer. C1 continued to display delusions when they approached staff asking for constipation medication stating, “I was raped from the back, and it hurts to try to make a bowel movement.” Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCMILLAN RANCH	FACILITY NUMBER: 425800215
	VISIT DATE: 08/23/2024

NARRATIVE

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The Client Treatment Plan for C1 indicates that C1’s Activities of Daily Living (ADL) are impaired due to their gross disorganization, difficulty following rules, avolition, difficulty concentrating, and frequent preoccupation with her delusions and hallucinations. Social relationships are impacted by C1’s delusions that people are out to do them harm, their tendency to isolate, and their preoccupation with their hallucinations. Comprehensive Assessment of C1 on 12/23/2021 revealed the following: Client presents with negative symptoms: Flat affect, diminished emotional expression, gross disorganization and avolition. Client also presents with auditory hallucinations daily, "entity talks to them daily one once talking then it comes out sounds like its things all around her happening like they are in a UFO." Client has daily delusions of knowing what others are thinking, high level government jobs (CIA), involvement with the Royal family, and the Vatican. Symptoms have been continuous and ongoing since client was a teenager. Client meets criteria for Schizophrenia. Symptoms currently impair client’s ability to maintain her ADL's: making/keeping appointments, ability to perform household chores, maintain finances, obtain food, maintain medication compliance. Client's social relationships are also significantly impacted as client believes that people are out to them harm and isolates. The Appraisal/Needs and Services (ANS) Plan for C1 indicates that C1 has been hospitalized in many Residential Care Facilities due to their preoccupation with delusions and hallucinations. C1’s diagnosis is Lupus but capable of doing daily living chores but will occasionally use impairments to avoid doing them. The Santa Barbara County Sheriff’s Office was involved in the IB investigation and did not suspect any evidence of a crime.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated.

Exit interview conducted. Copy of this report provided to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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