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Home My WebLink AboutPH-1 - 26-205 - 2. Hearing Officer Memorandum - 5/5/2026ECONOMIC & DEVELOPMENT SERVICES DEPARTMENT 77 FAIR DRIVE, POST OFFICE BOX 1200, COSTA MESA CA. 92628-1200 Building Safety Division (714) 754-5273 Community Improvement Division (714) 754-5638 Housing & Community Development (714) 754-4870 Planning Division (714) 754-5245 www.costamesaca.gov 1 | Page MEMORANDUM Item #: 25-01 Public Hearing Date: 10/23/2025 LOCATION: 1601 BAKER STREET FILE NO: PGSH-24-0002 REQUEST FOR: ALLOW A SOBER LIVING HOME WITH SIX OR FEWER PERSONS (NOT COUNTING THE HOUSE MANAGER) APPLICANT: GEORGE VILAGUT ON BEHALF OF STEPHOUSE RECOVERY INC. CEQA: PROJECT IS EXEMPT FROM CEQA: SECTION 15268 – MINISTERIAL PROJECTS AND SECTION 15301 – EXISTING FACILITIES PLANNER: VICTOR MENDEZ GENERAL PLAN: LOW DENSITY RESIDENTIAL (LDR) ZONING: R-1 – SINGLE FAMILY RESIDENTIAL The Special Use Permit (SUP) application (PGSH-24-0002) has been filed for a proposed single-unit sober living home, which will accommodate six recovery residents and one live- in house manager. The proposed site is located at 1601 Baker Street within the R1 zoning district and has been submitted by George Vilagut on behalf of Stephouse Recovery Inc. The project site encompasses approximately 0.16 acres and consists of a single parcel. It is currently developed with a 2,500 square-foot single-family residence built in 1959. The surrounding area consists of -family residential properties to the west, south, and east, with additional single-family homes located across Baker Street. BACKGROUND Facilities licensed by the state to care for up to six residents are exempt from local regulation per state law. However, in accordance with Costa Mesa Municipal Code (CMMC) Title 13, -1- ATTACHMENT 2 ECONOMIC & DEVELOPMENT SERVICES DEPARTMENT 77 FAIR DRIVE, POST OFFICE BOX 1200, COSTA MESA CA. 92628-1200 Building Safety Division (714) 754-5273 Community Improvement Division (714) 754-5638 Housing & Community Development (714) 754-4870 Planning Division (714) 754-5245 www.costamesaca.gov 2 | Page Chapter XV, unlicensed group homes serving up to six residents in any residential zone must obtain approval of a SUP. Presently, the Director of Economic and Development Services is authorized to issue the special use permit as a ministerial permit, based on the facility’s compliance with the adopted standards for location and operation. As a ministerial permit, review is limited to the objective standards identified in the zoning ordinance. At least 10 days prior to issuing a special use permit, the Director shall direct written notice to be mailed to the owner of record and occupants of all properties within 500 feet of the location of the group home to serve as notification of the permit and the hearing. Prior to the issuance of a SUP, the Director is obligated to hold a hearing, for the purpose of receiving information regarding compliance with applicable provisions pursuant to Costa Mesa Municipal Code (CMMC) subsections 13-311(a) and (b), in accordance with the limitations of a ministerial permit review. The purpose of the public hearing for a Special Use Permit for an unlicensed group home of six or fewer occupants (excluding the housing manager) is strictly to collect information on compliance with the applicable standards in Costa Mesa’s Municipal Code (e.g. § 13- 311). It is a ministerial process — staff’s role is limited to verifying whether the application conforms to the ordinance, not making discretionary judgments. Comments or concerns submitted by the public become part of the record and may provide factual evidence relevant to compliance. Staff and the applicant may respond to or clarify such information, but all decisions must be grounded in the objective requirements of the ordinance.The only instances the special use permit can be denied or revoked upon a determination, and if already issued shall be denied or revoked upon a hearing, by the Director that any of the following circumstances exist: (1)Any owner/operator or staff person has provided materially false or misleading information on the application or omitted any pertinent information; (2)Any owner/operator or staff person has an employment history in which he or she was terminated during the past two years because of physical assault, sexual harassment, embezzlement or theft; falsifying a drug test; and selling or furnishing illegal drugs or alcohol. (3)Any owner/operator or staff person has been convicted of or pleaded nolo contendere, within the last seven to 10 years, to any of the following offenses: i.Any sex offense for which the person is required to register as a sex offender under California Penal Code section 290 (last 10 years); -2- ECONOMIC & DEVELOPMENT SERVICES DEPARTMENT 77 FAIR DRIVE, POST OFFICE BOX 1200, COSTA MESA CA. 92628-1200 Building Safety Division (714) 754-5273 Community Improvement Division (714) 754-5638 Housing & Community Development (714) 754-4870 Planning Division (714) 754-5245 www.costamesaca.gov 3 | Page ii. Arson offenses—Violations of Penal Code Sections 451—455 (last seven years); or iii. Violent felonies, as defined in Penal Code section 667.5, which involve doing bodily harm to another person (last 10 years). iv. The unlawful sale or furnishing of any controlled substances (last seven years). (4) Any owner/operator or staff person is on parole or formal probation supervision on the date of the submittal of the application or at any time thereafter. (5) The owner/operator accepts residents, other than a house manager, who are not handicapped as defined by the FHAA and FEHA. (6) A special use permit for a sober living home shall also be denied upon a determination, and if already issued, any transfer shall be denied or revoked, upon a hearing, by the Director that any of the following additional circumstances exist: i. Any owner/operator or staff person of a sober living home is a recovering drug or alcohol abuser and upon the date of application or employment has had less than one full year of sobriety. ii. The owner/operator of a sober living home fails to immediately take measures to remove any resident who uses alcohol or illegally uses prescription or non- prescription drugs, or who is not actively participating in a legitimate recovery program from contact with all other sober residents. iii. The sober living home, as measured by the closest property lines, is located within 650 feet of any other sober living home or state licensed alcoholism or drug abuse recovery or treatment facility. If a state-licensed alcoholism or drug abuse recovery or treatment facility moves within 650 feet of an existing sober living home, this shall not cause the revocation of the sober living home's permit or be grounds for denying a transfer of such permit. (7) For any other significant and/or repeated violations of this section and/or any other applicable laws and/or regulations, including, but not limited to, failure to comply with the provisions of subsections (a)(10) through (13). -3- ECONOMIC & DEVELOPMENT SERVICES DEPARTMENT 77 FAIR DRIVE, POST OFFICE BOX 1200, COSTA MESA CA. 92628-1200 Building Safety Division (714) 754-5273 Community Improvement Division (714) 754-5638 Housing & Community Development (714) 754-4870 Planning Division (714) 754-5245 www.costamesaca.gov 4 | Page (8) Revocation shall not apply to any group home, which otherwise would cause it to be in violation of this section, that has obtained a reasonable accommodation pursuant to section 13-200.62 STANDARD OF REVIEW The project complies with CMMC Sections 13-32, 13-85 and 13-311, as shown in the project data table below. The home will accommodate six recovery residents and one full-time house manager ensuring adherence to the maximum occupancy limit. The group home will be in the primary dwelling unit, with no accessory dwelling unit on the property, meeting zoning standards that prohibit group homes in accessory units unless both units serve the same purpose. Parking requirements are satisfied, as the five-bedroom home requires a minimum of four parking spaces, and the property provides five on-site spaces—two in the garage and three in the driveway. Additionally, there are no other sober living homes or state-licensed alcoholism or drug abuse recovery or treatment facilities within a 650-foot radius of the proposed residence, ensuring compliance with the required separation distance. Furthermore, the application includes all required documentation in compliance with CMMC Section 13-311, including the written intake procedures and relapse policy. Based on the information provided and after a thorough review, the SUP application is approved, subject to the following conditions: 1. Prior to operation of the sober living home, the applicant shall schedule and pass an inspection by the Costa Mesa Fire Department to verify that the property meets the basic fire and life safety requirements for a single-family dwelling, including but not limited to the installation of smoke detectors and carbon monoxide (CO) detectors. 2. Failure to comply with the requirements listed in CMMC Section 13-311 may result in the revocation of this permit. PROJECT DATA TABLE - COMPLIANCE WITH KEY DEVELOPMENT STANDARDS Zoning Section DEVELOPMENT STANDARD CODE REQUIREMENT PROPOSED/ PROVIDED MEETS CODE Residential Development Standards - R1 Zone (CMMC 13- 32) Minimum Lot Area 6,000 SF 7,384 SF ✅ Yes Maximum Building/Structure Height 2 Stories / 27 FT 1 story / 15 FT 2 IN ✅ Yes -4- ECONOMIC & DEVELOPMENT SERVICES DEPARTMENT 77 FAIR DRIVE, POST OFFICE BOX 1200, COSTA MESA CA. 92628-1200 Building Safety Division (714) 754-5273 Community Improvement Division (714) 754-5638 Housing & Community Development (714) 754-4870 Planning Division (714) 754-5245 www.costamesaca.gov 5 | Page PROJECT DATA TABLE - COMPLIANCE WITH KEY DEVELOPMENT STANDARDS Zoning Section DEVELOPMENT STANDARD CODE REQUIREMENT PROPOSED/ PROVIDED MEETS CODE Maximum Density 1 Dwelling Unit per 6,000 Square Feet 1 Dwelling Unit ✅ Yes Setbacks: Front 20 FT 20 FT ✅ Yes Side – Left (Interior) 5 FT 11 FT ✅ Yes Side – Right (Interior) 5 FT 7 FT ✅ Yes Rear 10 FT 14 FT 6 IN ✅ Yes Front 20 FT 20 FT ✅ Yes Residential Off- Street Parking Standards - R1 Zone (CMMC 13- 85) Parking: Standard 4 5 ✅ Yes Group Homes - R1 Zone (CMMC 13- 311) Primary vs Accessory Dwelling Unit Group Home Must be in a Primary Dwelling Unit; Not Allowed in an Accessory Unit Unless the Primary Unit is Used for the Same Purpose Located in the Primary Dwelling Unit; No Accessory Secondary Unit on the Property or Proposed ✅ Yes Maximum Number of Occupants 6 or Fewer Occupants (Excluding House Manager) 6 Occupants (Excluding House Manager) ✅ Yes Minimum Distance From Another Sober Living Home or State Licensed Alcoholism or Drug Abuse Recovery or Treatment Facility ≥ 650 FT From Another Sober Living Home or State Licensed Facility Not Located Within 650 FT of Another Facility ✅ Yes -5- Zoning Section DEVELOPMENT STANDARD CODE REQUIREMENT PROPOSED/PROVIDED MEETS CODE Minimum Lot Area 6,000 SF 7,384 SF ✅ Yes Maximum Building/Structure Height 2 Stories / 27 FT 1 story / 15 FT 2 IN ✅ Yes Maximum Density 1 Dwelling Unit per 6,000 Square Feet 1 Dwelling Unit ✅ Yes Front 20 FT 20 FT ✅ Yes Side – Left (Interior)5 FT 11 FT ✅ Yes Side – Right (Interior)5 FT 7 FT ✅ Yes Rear 10 FT 14 FT 6 IN ✅ Yes Front 20 FT 20 FT ✅ Yes Standard 4 5 ✅ Yes Primary vs Accessory Dwelling Unit Group Home Must be in a Primary Dwelling Unit; Not Allowed in an Accessory Unit Unless the Primary Unit is Used for the Same Purpose Located in the Primary Dwelling Unit; No Accessory Secondary Unit on the Property or Proposed ✅ Yes Maximum Number of Occupants 6 or Fewer Occupants (Excluding House Manager) 6 Occupants (Excluding House Manager)✅ Yes Minimum Distance From Another Sober Living Home or State Licensed Alcoholism or Drug Abuse Recovery or Treatment Facility ≥ 650 FT From Another Sober Living Home or State Licensed Facility Not Located Within 650 FT of Another Facility ✅ Yes PROJECT DATA TABLE - COMPLIANCE WITH KEY DEVELOPMENT STANDARDS Residential Development Standards - R1 Zone (CMMC 13-32) Residential Off-Street Parking Standards - R1 Zone (CMMC 13-85) Group Homes - R1 Zone (CMMC 13-311) Parking: Setbacks: ATTACHMENT 1 -6- 12'-3" 11 ' BEDROOM#4 BEDROOM#5 BEDROOM#3 BEDROOM#2BEDROOM#1 KITCHEN LIVING ROOM DINING PROPERTY LINE = 67' PR O P E R T Y L I N E = 1 0 3 ' GARAGE 7' GATE 7' ' B L O C K W A L L F E N C E PCC CITY SIDEWALK EASEMENT BAKER ST A0 ='1'40' 1 VICINITY MAP PROJECT DATA PLAN SHEETS ATTACHMENT 2 -7- 12'-3" 11 ' BEDROOM#4 BEDROOM#5 BEDROOM#3 BEDROOM#2BEDROOM#1 KITCHEN LIVING ROOM DINING PROPERTY LINE = 67' PR O P E R T Y L I N E = 1 0 3 ' GARAGE 7' GATE 7' ' B L O C K W A L L F E N C E PCC CITY SIDEWALK EASEMENT A1 24" 30 " 15 " 15 " TYPICAL TOILET MINIMUM CLEARANCE REQUIREMENTS CLEARANCE FOR WATER CLOSETS TO BE A MINIMUM OF 24" IN FRONT ND 15" FROM CENTER TO ANY SIDE WALL OR OBSTRUCTION. ='1'40' -8- 7' - 1 0 " 15 ' - 2 " 12 ' - 8 " REAR ELEVATION A2 NORTH ELEVATION SOUTH ELEVATION -9- STUCCO ROOF GLASSALUMINUM WOODEN DOORGLASS ALUMINUM STUCCO ROOF A3 EAST ELEVATION WEST ELEVATION -10- BA K E R S T R E E T PROPERTY LINE FENCESOLAR PROPERTY LINE BOUNDARY WALL DRIVEWAY 105'-8" 67 ' - 5 " 105'-9" EX I S T I N G D W E L L I N G SITE PLAN Scale 1/8" = 1'-0" ROOF PLANS GENERAL NOTES 1. INSULATION HAS 1" MIN. AIR SPACE ABOVE IN VAULTED CEILING. 2. INSTALLATION OF ROOFING SHALL BE IN ACCORDANCE WITH MANUFACTURES SPECIFICATIONS. 3. COMPOSITION SHINGLE ROOF OVER LAPPED 30# A.S. FELT (TYP. THRU OUT) 4. COORDINATE INSTALLATION OF NEW ROOFING WITH OTHER TRADES. REPORT ANY CONFLICTS WITH ITEMS INSTALLED BY OTHER TRADES TO DESIGNER. 5. ALL ROOF CURBS FOR NEW ROOFTOP EXHAUST FANS , HVAC UNITS AND CONDENSING UNITS SHALL HAVE CURB HEIGHTS THAT WILL ALLOW FOR A MINIMUM OF 8" BASE FLASHING HEIGHTS FOR THE ROOF SYSTEM. 6. ALL PLUMBING VENTS SHALL EXTEND ABOVE THE FINISHED SURFACE OF THE ROOF SYSTEM AS REQUIRED TO PROVIDE FOR A MINIMUM OF 8" BASE FLASHING. 7. PROVIDE 36" WIDE WALK PADS @ SERVICE SIDE OF ALL MECH. EQUIPMENT. 8. ALL EXPOSED METAL FLASHING/ TRIM PIECES TO BE PRE-FINISHED 24 GA. STL. U.N.O.. PROVIDE PRE-FINISHED OR FIELD PAINT FLASHING ONLY AS NOTED. 9. R903.4.1 OVERFLOW DRAINS AND SCUPPERS. WHERE ROOF DRAINS ARE REQUIRED, OVERFLOW DRAINS HAVING THE SAME SIZE AS THE ROOF DRAINS SHALL BE INSTALLED WITH THE INLET FLOW LINE LOCATED 2 INCHES (51 MM) ABOVE THE LOW POINT OF THE ROOF, OR OVERFLOW SCUPPERS HAVING THREE TIMES THE SIZE OF THE ROOF DRAINS AND HAVING A MINIMUM OPENING HEIGHT OF 4 INCHES (102 MM) SHALL BE INSTALLED IN THE ADJACENT PARAPET WALLS WITH THE INLET FLOW LOCATED 2 INCHES (51 MM) ABOVE THE LOW POINT OF THE ROOF SERVED. THE INSTALLATION AND SIZING OF OVERFLOW DRAINS, LEADERS AND CONDUCTORS SHALL COMPLY WITH THE CALIFORNIA PLUMBING CODE. 10. PROVIDE ICE BREAKS AT ALL PERIMETER AREAS OF STANDING SEAM ROOFING. 11. PROVIDE 36" WIDE WALK PADS @ SERVICE SIDE OF ALL MECH. EQUIPMENT. & PROVIDE 36" WIDE WALK PADS AROUND ALL ROOF HATCHES & 72"X72" PADS AT LADDERS. 12. ALL EXPOSED METAL FLASHING/ TRIM PIECES TO BE PRE-FINISHED 24 GA. STL. U.N.O.. PROVIDE PRE-FINISHED OR FIELD PAINT FLASHING ONLY AS NOTED. 13. GUTTERS - ALL GUTTERS TO BE PRE-FINISHED 24 GA. STL. . PROVIDE PRE-FINISHED GALV. STL. BENT PLATE BRACKETS AND 14GAX1" GALV. STL. SPACERS @ 36" O.C. MAX. - STAGGER W/ EACH OTHER @ 18" O.C.. PROVIDE PRE-FORMED 14. GUTTER E.J.'S PER SMACNA FIG. 1-7, TYP. @ 30'-0" MAX.. PROVIDE S.S. SCREENS @ ALL GUTTERS PER SMACNA FIG 1-24. 15. ALL DOWNSPOUTS TO BE PRE-FINISHED 24 GA. GALV. STL., PER SMACNA FIG 1-32B. DOWNSPOUTS ARE 6"X6" U.N.O., LOCATED AS NOTED ON ROOF PLAN. 15GA.X2" GALV. STL. HANGERS @ 48" O.C. MAX. PER SMACNA FIG 1-35B. 16. PROVIDE PAINTED 4' TALL CAST ALUM. DOWNSPOUT BOOTS @ ALL DOWN SPOUTS, TIE INTO SUB-GRADE DRAINAGE, RE: CIVIL. 17. TAPERED INSULATION TO BE 1/4" PER FOOT MIN. SLOPE TO DRAIN. ROOF PLAN SHOWS TAPERED INSULATION FOR GRAPHIC REPRESENTATION ONLY. CONTRACTOR TO VERIFY INSULATION REQUIRED TO SLOPE PRIOR TO MEMBRANE INSULATION. 18. PROVIDE TAPERED INSULATION CRICKETS 1/4" PER FOOT MIN. SLOPE @ HIGH SIDE OF ALL MECHANICAL UNITS AND ROOF HATCHES, TO SHED WATER AROUND AND MAINTAIN POSITIVE ROOF DRAINAGE. 19. ALL WOOD BLOCKING AT ROOF EDGES, RIDGES, ETC. TO BE 2X FR-WD BLOCKING. 20. VERIFY ELEVATION OF ROOF DRAIN RELATIVE TO OVERFLOW SCUPPER PRIOR TO INSTALLATION OF SCUPPERS A4 1/2" CDX PLY APROVED ROOF COVERING ALTERNATE LOCATION OF GWB OR 2X BLOCKING IF NO CEILING FINISH IS 2X4 BLOCK FASCIA PROVIDED SOFFITBOARD 5/8 TYPE XGYPSUM SHEATING STUCCO FINISH 5/8 TYPE XGYPSUM WALLBOARD 2X FRAMING STRUCTURALSHEATING ASREQUIRED 1 HOUR RATED WALL AND4 SCALE: NTSPROTECTED EAVE OVERHANG NOTES: 4" MIN. - THE ROOF OVERHANG CANNOT EXCEED 12" AND MUST BE ONE-HOUR PROTECTED OR EQUAL ON UNDERSIDE IF ADU IS LOCATED UNDER 5' FROM PROPERTY LINE OVERHANG SHALL BE ADJUSTED TO MIN. REQUIRED. AS PER CODE SECTION R302 12" OR -11- 8' - 0 " A-A (NTS) A5 5 1 HOUR FIRE - GENERIC SCALE: NTSEXTERIOR WALLS GYPSUM WALLBOARD, GYPSUM SHEATHING, WOOD STUDS EXTERIOR SIDE: ONE LAYER 48" WIDE 5/8" TYPE X GYPSUMSHEATHING APPLIED PARALLEL TO 2X4 WOOD STUDS 24" O.C. WITH 1-3/4" GALVANIZED ROOFING NAILS 4" O.C. AT VERTICALJOINTS AND 7" O.C. AT INTERMEDIATE STUDS AND TOP AND BOTTOM PLATES. JOINTS OF GYPSUM SHEATHING MAY BE LEFT UNTREATED. EXTERIOR CLADDING TO BE ATTACHED THROUGH SHEATHING TO STUDS. INTERIOR SIDE: ONE LAYER 5/8" TYPE X GYPSUM WALLBOARD,WATER-RESISTANT GYPSUM BACKING BOARD, OR GYPSUM VENNER BASE APPLIED PARALLEL OR AT RIGHT ANGLES TOSTUDS WITH 6d COATED NAILS, 1-7/8" LONG, 0.0915" SHANK, 1/4"HEADS, 7" O.C. (LOAD-BEARING) THICKNESS: VARIESAPPROX. WEIGHT: 7 PSFFIRE TEST: SEE WP 3510(UL R3501-47,-48,9-17-65 UL DESIGN U309,UL R1319-129, 7-22-70,UL DESIGN U314) EXTERIOR SIDE INTERIOR SIDE SECTION A-A -12- Legal_Name Facility_Address Facility_Address_2 Facility_City Facility_State Facility_Zip Distance from 1601 Baker St (Feet) Distance from 1601 Baker St (Miles) NEW DIRECTIONS FOR WOMEN, INC.2601 WILLO LANE COSTA MESA CA 92627 17,952 ft 3.4 mi SOUTH COAST COUNSELING, INC.693 PLUMER STREET COSTA MESA CA 92627-2720 13,728 ft 2.6 mi OPUS HEALTH, LLC 925 VICTORIA STREET COSTA MESA CA 92627 11,088 ft 2.1 mi RESURGENCE CALIFORNIA, LLC 3151 AIRWAY AVENUE SUITE K203 COSTA MESA CA 92626 16,368 ft 3.1 mi NANCY CLARK AND ASSOCIATES, INC.1110 VICTORIA STREET COSTA MESA CA 92627 11,616 ft 2.2 mi BREAKAWAY HEALTH CORPORATION 3151 AIRWAY AVE SUITE D-1/D-2 COSTA MESA CA 92626 16,368 ft 3.1 mi YELLOWSTONE WOMEN'S FIRST STEP HOUSE, INC.3132 BOSTON WAY COSTA MESA CA 92626 19,008 ft 1.5 mi YELLOWSTONE WOMEN'S FIRST STEP HOUSE, INC.154 EAST BAY STREET COSTA MESA CA 92627-2147 15,840 ft 3 mi YELLOWSTONE WOMEN'S FIRST STEP HOUSE, INC.2028 FULLERTON AVENUE UNIT A, B & C COSTA MESA CA 92627 15,840 ft 3 mi YELLOWSTONE WOMEN'S FIRST STEP HOUSE, INC.590 TRAVERSE DRIVE COSTA MESA CA 92626 15,840 ft 3 mi SAFE HARBOR TREATMENT CENTER FOR WOMEN, INC.546 BERNARD STREET COSTA MESA CA 92627 14,784 ft 2.8 mi SAFE HARBOR TREATMENT CENTER FOR WOMEN, INC.240 KNOX STREET COSTA MESA CA 92627 20,592 ft 3.9 mi SAFE HARBOR TREATMENT CENTER FOR WOMEN, INC.236 KNOX STREET COSTA MESA CA 92627 20,064 ft 3.8 mi MONROE OPERATIONS, LLC 3189 PULLMAN STREET COSTA MESA CA 92626 18,480 ft 3.5 mi ARROWOOD CAPITAL, INC. 1640 SUPERIOR AVE COSTA MESA CA 92627 19,008 ft 3.6 mi DREAM RECOVERY LLC 3188 AIRWAY AVE BLDG J COSTA MESA CA 92626 18,480 ft 3.5 mi DIVINE BLISS 1219 PARNELL PLACE COSTA MESA CA 92626 5,280 ft 1 mi HOTEL CALIFORNIA BY THE SEA, LLC 1509 ORANGE AVENUE A COSTA MESA CA 92627 20,064 ft 3.8 mi THE ALAMO LIVINGOOD CENTER, INC 3151 AIRWAY AVENUE SUITE J-2 COSTA MESA CA 92626 16,368 ft 3.1 mi AKUA BEHAVIORAL HEALTH, INC.369 RALCAM PLACE COSTA MESA CA 92627 10,560 ft 2 mi PARTNERS PROJECT INC.1001 W 17TH ST SUITE A COSTA MESA CA 92627 16,992 ft 3.22 mi SOUTH COAST BEHAVIORAL HEALTH 559 PIERPONT DRIVE COSTA MESA CA 92626 15,312 ft 2.9 mi SOUTH COAST BEHAVIORAL HEALTH 3129 PIERCE AVE COSTA MESA CA 92660 6,389 ft 1.21 mi CASA CAPRI LLC 671 GOVERNOR STREET COSTA MESA CA 92627 14,256 ft 2.7 mi COMPASS RECOVERY, INC.3151 AIRWAY AVENUE F105-B COSTA MESA CA 92626 16,368 ft 3.1 mi KKB HEALTH SOLUTIONS, LLC 2822 MONTEREY AVENUE COSTA MESA CA 92626 7,392 ft 1.4 mi TEAGLE HALL LLC 316 HAMILTON STREET COSTA MESA CA 92627 13,728 ft 2.6 mi TEAGLE HALL LLC 2136 THURIN STREET UNIT B COSTA MESA CA 92627 13,200 ft 2.5 mi TEAGLE HALL LLC 395 VICTORIA STREET COSTA MESA CA 92627 12,144 ft 2.3 mi TEAGLE HALL LLC 2136 THURIN STREET UNIT A COSTA MESA CA 92627 13,200 ft 2.5 mi TEAGLE HALL LLC 2137 DOCTORS CIRCLE UNIT A COSTA MESA CA 92627 13,200 ft 2.5 mi TEAGLE HALL LLC 2137 DOCTORS CIRCLE UNIT B COSTA MESA CA 92627 13,200 ft 2.5 mi RECOVERY SOLUTIONS, LLC 209 E. 18TH STREET COSTA MESA CA 92627 15,312 ft 2.9 mi JJLT HOLDINGS LLC 1799 HUMMINGBIRD DRIVE COSTA MESA CA 92626 7,920 ft 1.5 mi EMBRACE TREATMENT LLC 1912 SUMBA CIRCLE COSTA MESA CA 92626 7,920 ft 1.5 mi ELITE CARE, INC.930 MAGELLAN STREET COSTA MESA CA 92626 9,082 ft 1.72 mi AKUA BEHAVIORAL HEALTH, INC.326 UNIVERSITY DRIVE COSTA MESA CA 92627 16,896 ft 3.2 mi AKUA BEHAVIORAL HEALTH, INC.319- A UNIVERSITY DR.COSTA MESA CA 92627 16,896 ft 3.2 mi AKUA BEHAVIORAL HEALTH, INC.319- B UNIVERSITY DR.COSTA MESA CA 92627 16,896 ft 3.2 mi RISING ROADS RECOVERY SERVICES FOR WOMEN, LLC 3151 AIRWAY AVENUE SUITE I-3 COSTA MESA CA 92626 16,368 ft 3.1 mi SAFE AND SOUND TREATMENT, LLC 3151 AIRWAY AVE L2 COSTA MESA CA 92626 16,368 ft 3.1 mi BEACH CITIES RECOVERY LLC 440 FAIR DRIVE SUITE 237 COSTA MESA CA 92626 7,920 ft 1.5 mi FRESH START RECOVERY SVCS 204 E 17TH STREET SUITE 203 COSTA MESA CA 92627 19,008 ft 3.6 mi Substance Use Disorder Treatment Facilities ATTACHMENT 3 -13- FOOTPRINTS IN THE SAND 2 RECOVERY LLC 653 W. 19TH STREET COSTA MESA CA 92627 13,200 ft 2.5 mi RENU HEALTHCARE, LLC 1008 W WILSON ST SUITE A COSTA MESA CA 92627 10,032 ft 1.9 mi RENU HEALTHCARE, LLC 1008 W WILSON ST SUITE B COSTA MESA CA 92627 10,032 ft 1.9 mi OASIS TREATMENT CENTERS, LLC 1901 NEWPORT BLVD SUITE 271 COSTA MESA CA 92627 19,008 ft 3.6 mi AMLA FAMILY COUNSELING INC.2900 BRISTOL ST SUITE 320 COSTA MESA CA 92626 10,560 ft 2 mi CHANGES MH LLC 2787 BRISTOL STREET COSTA MESA CA 92627 10,032 ft 1.9 mi -14- Program Name Street Name City State Zip Project No. Distance from 1601 Baker St (Feet) Distance from 1601 Baker St (Miles) Summit Coastal Living 165 E Wilson Street Costa Mesa CA 92627 PA-16-03 15,312 ft 2.9 mi Summit Coastal Living 2041 Tustin Ave Costa Mesa CA 92627 PA-16-04 20,064 ft 3.8 mi South Coast Behavioral Health 506 Traverse Drive Costa Mesa CA 92626 SL-15-0001 16,896 ft 3.2 mi The Ohio House 862 Senate Street Costa Mesa CA 92627 SL-15-0002 14,784 ft 2.8 mi Keystone Sober Living 2152 Raleigh Avenue Costa Mesa CA 92627 SL-15-0014 14,256 ft 2.7 mi Breakaway Health Corp.492 Broadway Costa Mesa CA 92627 SL-15-0017 21,120 ft 4 mi California Women's Recovery 2735 Cibola Avenue Costa Mesa CA 92626 SL-15-0018 9,504 ft 1.8 mi Agape House 2879 Monterey Costa Mesa CA 92626 SL-15-0031 7,392 ft 1.4 mi Republic House 2064 Republic Avenue Costa Mesa CA 92627 SL-15-0033 17,952 ft 3.4 mi Providence Recovery 582 Pierpont Drive Costa Mesa CA 92626 SL-15-0038 15,312 ft 2.9 mi Northbound Treatment Services 331 16th Place Costa Mesa CA 92627 SL-16-0004 21,120 ft 4 mi South Coast Counseling, Inc.693 Plumer Street Costa Mesa CA 92627 ZE-81-87 13,728 ft 2.6 mi First Step House / Mcmillen House 2015 Charle Street Costa Mesa CA 92627 PA-91-93 11,616 ft 2.2 mi The Joshua House, National Therapeutic Services 209-211 E 18th Street Costa Mesa CA 92627 PA-87-166 15,312 ft 2.9 mi First Step House 2025 Charle Street Costa Mesa CA 92627 PA-95-14 11,616 ft 2.2 mi Nancy Clark and Associates, Inc.1110 Victoria Street Costa Mesa CA 92627 PA-97-36 11,616 ft 2.2 mi City Approved Sober Living/Group Homes ATTACHMENT 4 -15- August 26, 2024 Re: Special Use Permit for Sober Living To: The City of Costa Mesa 1. i.The residence at 1601 Baker St. Costa Mesa, CA 92626 is owned by George Vilagut, who currently resides at . Phone number California Driver License number ii.Stephouse Recovery, Inc is a corporation. a.George Vilagut is the sole owner, there are no partners b.George Vilagut maintains controlling interest in the corporation c.Please see Exhibits A and A-1 for the Board of Directors resolution designating George Vilagut as the permit holder. iii.Please see Exhibit B for the permit and licenses history for Stephouse Recovery. iv.The House Manager is Zachary Place who currently resides at 1601 Baker Street. His phone number is , California Driver’s License number . Zach passed his background screening with the Orange County Sheriff's Department. All Stephouse employees and volunteers must be screened by the OC Sheriff's Department prior to hire date. He will reside at the Sober Living Residence 7 days a week, 24 hours a day and will be responsible for the daily operations of the home. Please note that Stephouse Recovery has provided a copy of our Policies and Procedures manual in its entirety. In addition, we have provided EXHIBIT C, which contains only the policies requested for the SUP. v.Good Neighbor Policy – please see Exhibit C, Stephouse Recovery Policies for SUP, page 1. vi.Intake Procedure - please see Exhibit C, Stephouse Recovery Policies for SUP, page 2. vii.Relapse Policy - please see Exhibit C, Stephouse Recovery Policies for SUP, page 2. viii.Affirmation by Owner – please see Exhibit D ATTACHMENT 5 -16- ix.Intake Packet -please see Exhibit E. The packet contains all blank forms that residents are required to sign during the intake process x.The application processing fee was paid on June 27, 2024. 2.Stephouse Recovery Inc. is requesting a Special Use Permit (SUP) from the City of Costa Mesa to establish a Sober Living Residence at 1601 Baker St. Costa Mesa, CA 92626. It is proposed that the Sober Living Residence house six (6) recovery residents and one full time house manager. The facility will only be available to approved residents, and never open to the public. Visitors are not permitted at Stephouse Recovery homes. The Executive Director and Compliance Officer for Stephouse provide support and management to the house manager. Stephouse Recovery is contracted with the Orange County Health Care Agency (OCHCA) and is subject to their active oversight and governance. Stephouse Recovery is also inspected and certified annually by the Orange County Sheriff’s Department. Due to a severe shortage of sober living beds, Stephouse Recovery seeks to add the Baker residence to assist OCHCA in meeting the needs of the community. We propose that obtaining this Special Use Permit and opening the Baker residence will have no negative impact on the neighborhood. Stephouse Recovery successfully operates several sober living facilities in Orange County and maintains positive and harmonious relationships with all neighbors. 3.The Baker property does not have an accessory secondary unit on site. Residents shall live in the only home on the property. 4.The house manager will reside at the residence providing round-the-clock supervision and oversee daily operations. The house manager is also responsible for monitoring residents and ensuring they are safe and adhere to all rules and regulations. 5.The Baker property allows for five (5) vehicles to be parked on site. Two (2) garage spaces and three (3) driveway spaces. Please see the Motor Vehicle Policy, page 2, Exhibit C, for additional information on how Stephouse Recovery meets this requirement. 6.Stephouse does not provide supervised care, counseling, treatment, or recovery planning. Residents must be capable of living independently. Stephouse Recovery’s target population includes adult women and men who are transitioning from substance abuse treatment to mainstream living. 7.The Baker property is not an integral group home facility. This statement is included in the Affirmation by Owner, Exhibit D. 8.Not Applicable – the Sober Living Home operator is also the property owner. 9.Stephouse Recovery is prepared to meet this requirement upon physical inspection by the City of Costa Mesa. 10.Please see Stephouse Recovery’s Discharge/Termination Policy, page 3 of EXHIBIT C. i.Stephouse Recovery Staff will notify a residents emergency contact of termination only in the event of an emergency and/or if the resident has signed a release of information allowing us to share such information. Otherwise, an emergency contact will only be notified in the event of an actual emergency. ii.Because Stephouse Recovery contracts with the OC HCA, we are required to notify the county when a resident is discharged without completion. Each resident is assigned a case manager by the county who facilitates next steps for -17- the individual. In most situations of relapse and/or mental health crisis, Stephouse Recovery will transport the individual to College Hospital or Be Well Orange Campus. At times the resident must be transported via ambulance. iii. Due to HIPAA and County Regulations, Stephouse Recovery would not be able to notify any other agency of a resident’s status without a signed release of information. However, Stephouse Recovery does provide housing resources for residents at intake and if necessary, will assist a resident in securing temporary housing at discharge. iv. Residents are notified of Stephouse Recovery’s Discharge Policy and available resources at intake. An acknowledgement form for their initial and signature is included in the intake packet. Stephouse will include the City form for discharged Baker residents. v. Stephouse Recovery will ensure that we follow steps i through iv as outlined above if a resident’s behavior or relapse requires immediate termination of residency. 11. Please see Stephouse Recovery’s Discharge Procedures for Staff, page 4, EXHIBIT C, that outlines how Stephouse follows this requirement. 12. Please see Stephouse Recovery’s Records Management and Maintenance Policy, page 5, EXHIBIT C, and Record’s Retention Policy, page 6, EXHIBIT C. 13. Please see Stephouse Recovery’s Transportation Policy, page 7, EXHIBIT C. 14. Additional Regulations: i. Stephouse Recovery is not aware of any other sober living home, or a state licensed alcoholism or drug abuse recovery or treatment facility located within 650 feet, as measured from the closest property lines. ii. OC HCA requires that all residents attend an Orange County approved Intensive Outpatient Treatment Program (IOP), and sobriety support meetings (such as Alcoholics Anonymous) while living at the residence. Residents are required to provide a letter of enrollment in IOP within one week of being admitted to Sober Living. Residents are required to turn in a meeting log every Sunday listing all meetings attended for the week and initialed by the facilitator or counselor who ran the meeting. Residents are also asked to sign a release of information so that Stephouse may check in with meeting facilitators and counselors to confirm attendance. iii. Stephouse Recovery policies and procedures state zero tolerance for drug and alcohol throughout. The Drug/Alcohol Policy, page 7, EXHIBIT C, specifically addresses prohibition of drugs and alcohol use, distribution, and/or possession. The Drug/Alcohol Policy is posted at every Sober Living Home. iv. Please see Stephouse Recovery’s Denied Admission Policy page 7, EXHIBIT C, stating our procedures for registered sex offenders. -18- v. Stephouse Recovery has a strict “no visitors” policy. A “No Visitors Allow” sign is posted at the residence and the house manager enforces this policy. Please see Exhibit C, Stephouse Recovery Policies for SUP, page 8, for the Visitation Policy. vi. Please see Exhibit C, Stephouse Recovery Policies for SUP, page 1, for the Good Neighbor Policy. vii. Stephouse Recovery Sober Living Homes do not provide individual or group counseling, treatment of any kind, or recovery planning. Residents are referred to outside agencies for these services. 15. House Dimensions and Floor Plan i. A site plan is not required for this project. ii. The Baker residence is a 2200 square foot single family residence. Please see EXHIBIT F for: a. Room layouts and dimensions. b. Room labels c. Location of walls, doors, and windows iii. Please see EXHIBIT G for exterior images of the Baker property. 16. Modifications to the applicant letter: a. Provide operation characteristics of the facility including proposed number of employees, residents, hours of operation, hours of operation for front door/garage doors being open to the public. As previously stated, the Baker house will be a Sober Living Residence that houses up to six (6) recovery residents and one full time house manager. There are no hours of operation as at no time will the residence be open to the public. Support staff for the house manager include the Office Administrator, Executive Director, and Compliance Officer. Stephouse Recovery is contracted with the Orange County Health Care Agency (OCHCA) Residential Recovery Services program and is subject to their active oversight and governance. The County allows participants to stay in sober living for 120 days. At the end of the 120 days, residents are expected to have obtained employment and stable housing. Stephouse Recovery is required to document and report to the County each resident’s progress with these goals at the end of every month. Stephouse conducts weekly drug and alcohol screenings. Drugs screenings are reported to OCHCA at the end of every month. Depending upon the circumstances of a resident’s relapse, they could be put on a behavior contract, or immediately discharged. The County monitors our outcomes. b. Provide details on the specific services or programs that will be offered to support residents in their recovery. The Baker house will be an extension of the OCHCA Residential Recovery Services Program. Stephouse does not offer specific services or programs. Rather we provide a safe independent living environment that supports sobriety by promoting a sense of community and accountability. Residents are held accountable to attending regular support meetings, outpatient treatment, and forming a plan for employment, and future stable housing. -19- c. Clarify how the facility will handle conflicts or issues between residents to maintain a positive living environment. The house manager is trained in de-escalation techniques to assist him in mediating conflicts between residents. At orientation, residents are informed they must treat each other with respect and that aggressive behaviors, yelling, and fighting will result in a behavior contract and/or immediate discharge. When residents struggle to get along, a Stephouse Administrator will call a house meeting to discuss issues and facilitate compromise among those in conflict. Facilitating open communication between residents has been very helpful with ensuring harmony in the residence. d. Identify the training and qualifications of the staff or house managers overseeing the residence. The house manager is required to have at least one year of sobriety and may not be on parole or probation. The house manager is required to attend several training sessions provided by OCHCA and Stephouse Recovery that must be completed within 30 days of hire, and annually thereafter. Trainings include: • Annual Provider Training • Cultural Competency Training • Crisis Intervention Training (situational awareness & de-escalation techniques) • Infectious Disease Recognition Training • CPR certification • Recognizing physical & psychiatric symptoms (to know when residents need a higher level of care) • HIPPA, Privacy and Confidentiality Training • Naloxone Administration Training e. Describe the procedures in place for ensuring that residents adhere to the facility's rules, especially regarding substance use and participation in recovery programs. Residents receive random weekly drug and alcohol screening to ensure continued sobriety. Residents are required to turn in a meeting log every Sunday listing all meetings attended for the week. Log entries must be initialed by the facilitator or counselor who ran the meeting. Residents are also asked to sign a release of information so that Stephouse may check in with meeting facilitators and counselors to confirm attendance. At times, the resident will authorize their meeting places to contact Stephouse if they have been absent from their recovery programs. Because a big part of the OC Residential Recovery Program is to ensure residents are employed, volunteering, or attending school, Stephouse provides a computer, printer and internet access with job hunting and resume writing resources, as well as connections to organizations seeking volunteers. Unemployed residents are required to provide proof that they have applied for work and completed volunteer hours. If they are working, Stephouse will periodically request copies of paystubs. Students must provide confirmation of enrollment, and their school schedule. Stephouse -20- Recovery is required to report our employment and housing outcomes to OCHCA monthly. f. Explain how the sober living home will communicate and engage with the local community and address any concerns or feedback from neighbors. StepHouse Recovery provides contact information of our managerial staff to the bordering neighbors (located behind, to the left, to the right, as well as across the street of each recovery residence). We provide bordering neighbors with an "Introductory Letter" informing them of our presence in the community and our mission and efforts to help those in recovery make their fresh start in a safe and sober environment. "Introductory Letters" also include the contact information for our County Program Officers so that neighbors may can reach out to them should they feel Management is not addressing their concerns. Should a neighbor contact a house manager with a complaint regarding our home or its occupants, it is the responsibility of the house manager to pass this information to Management immediately, failure to do so will result in a written warning. Management will respond to the complaint within 24 hours to let the concerned neighbor know that the complaint was received and that we are investigating the situation. The complainant will receive a follow up call once an investigation is complete. Please see Stephouse Recovery Good Neighbor Policy and EXHIBIT H -Introductory Letter to Neighbors, for more information. g. Outline the process for screening and selecting residents to ensure suitability for the sober living environment. Residents are pre-screened by the OCHCA Gatekeeper prior to referral to a Stephouse Residence. Stephouse Recovery then screens all referrals at time of intake. Criteria to qualify for enrollment includes • A willingness to continue sobriety • Abstinence from drugs and alcohol for at least one month prior to admittance • Successful completion of a detox and treatment program. • No one who is under the influence or displaying questionable or dangerous behaviors will be admitted to Stephouse Recovery. OCHCA requires that staff are trained in Recognizing Symptoms Requiring Appropriate Referral. Should a referral be denied admission, the person will be referred back to the OC HCA Gatekeeper for appropriate placement. Residents must be gainfully employed or enrolled in school as a condition of their residency. Residents must also be capable of living independently. h. Provide information on how the facility will ensure that residents have access to necessary medical and psychological support services. Stephouse residents are provided outpatient treatment for mental health and substance abuse through OCHCA. Because they are part of a county program, residents are Medi-Cal eligible. Stephouse ensures that residents understand the Medi-Cal services they are eligible for, that they have their Medi-Cal card and where they can go for medical treatment, and pharmacy needs. -21- i. Clarify the measures in place to ensure compliance with the city’s parking and traffic regulations, particularly for visitors and staff vehicles. Residents are notified of parking and pickup/drop off rules when they intake. Stephouse has two (2) garage parking spaces, and (3) driveway spaces for the house manager and residents. This will leave a possible need for two (2) vehicles to be parked in front of the residence. However, it is rare for more than two (2) residents to have a vehicle at any given time. Stephouse residents are not allowed to have visitors. j. Identify the facility’s emergency response plan and procedures for handling situations such as medical emergencies or behavioral issues. In the event of an emergency, residents and staff are directed to call 911 to dispatch emergency personnel. The house manager will notify the Executive Director of the situation and discuss next steps depending upon the circumstances. Please see the Stephouse Recovery Emergency Response Plan, page 7, EXHIBIT C, for more information. While the house manager is training in crisis intervention/de- escalation, the police will be summoned should a resident’s behavior become over aggressive, or dangerous. k. Describe how the sober living home will ensure transparent operations and regular reviews for compliance with all applicable regulations and city standards. Stephouse Recovery has developed and regularly updates strict operating policies for residents and staff. Monitoring curfews, completing regular random drug and alcohol screenings, and nightly bed checks facilitate Stephouse’s attention to compliance with County and City regulations and standards. Stephouse has an open-door policy with law enforcement, county program officers, and code enforcement. Stephouse is subject to annual County chart audits, site visits, contract audits, and inspections by the OC Sheriff’s Department. Every resident can file a complaint or grievance with County Program Officers. These complaints are anonymous and promptly investigated. l. Describe the facility’s strategy for maintaining a clean and safe environment, including regular inspections and maintenance procedures. Stephouse is subject to annual County chart audits, site visits, contract audits, and inspections by the OC Sheriff’s Department. We employ a gardening and landscaping company to maintain the yards and plants at each residence. We also employ a full-time maintenance person to address needed repairs, pest control, and other necessary updates to the properties. Stephouse Recovery requires that residents participate in keeping the residence and property clean and safe by assigning weekly household chores. m. Identify any additional resources or amenities that will be offered to residents to support their daily living and overall well-being, such as job training or life skills workshops. Stephouse Recovery provides a computer, printer, and WiFi to assist residents in securing employment and searching for stable housing. We do not provide other skill building or workshops because the residents receive this type of support through their weekly IOP provider meetings. Our primary goal is to provide a safe, sober -22- -23- SPECIAL USE PERMIT APPLICATION SUPPORTING DOCUMENTS TABLE OF CONTENTS page EXHIBIT A -Stephouse Recovery Resolution 150 2 EXHIBIT A1- Resolution 150 Certification 3 EXHIBIT B Permit History for Stephouse Recovery (includes permits, licenses) 4 EXHIBIT C Stephouse Recovery Policies for SUP 11 Good Neighbor Policy 11 Intake Policy & Procedure 12 Client Relapse Policy 12 Motor Vehicle Policy 12 Discharge/Termination Policy 13 Discharge Procedures for Staff 14 Records Management & Maintenance 15 Record Retention Policy 16 Transportation Policy 17 Drugs/Alcohol Policy 17 Denied Admission Policy 17 Emergency Response Plan 17 Visitation Policy 18 EXHIBIT D Affirmation of Resident Disability Status & Integral Use 19 EXHIBIT E Facility Intake Packet for Residents Signature 20 EXHIBIT H Introductory Letter to the Neighborhood 59 Please note that EXHIBITS F & G were uploaded to the portal separately. A copy of the full Policies and Procedures Manual for Stephouse Recovery is available upon request. 1-24- EXHIBIT A 2-25- EXHIBIT A-1 3-26- Permit History for Stephouse Recovery Stephouse Recovery began providing detox, treatment, and recovery services in Fountain Valley in 2011. Stephouse was licensed by the State of California Department of Health Care Services, with the license set to expire in May of 2023. Stephouse was also accredited through The Joint Commissions. However, due to operating challenges brought on by the COVID-19 pandemic and a decline in claim reimbursements from insurance companies, Stephouse made the difficult decision to discontinue treatment and detox services. In early 2022, Stephouse notified the State of their decision and relinquished DHCS licenses for all their facilities. Existing treatment centers became recovery sober living homes only. In 2019, Stephouse Recovery was awarded a contract with Orange County Health Care Agency’s Residential Recovery Services Program. Under that contract, Stephouse is required to have a business license from every city in which they operate. Each residence is also required to be inspected and certified annually by the Orange County Sheriff’s Department. Stephouse Recovery has been in good standing with the City of Fountain Valley for many years and has current business licenses for two sober living homes in that city. Fountain Valley recently voted to require special use permits for Sober Living Homes. Stephouse has complied, and an application was submitted to the city in early June 2024. The city is currently processing that application. In 2023, Stephouse opened a Sober Living Home in Huntington Beach and was granted a special use permit. Stephouse remains in good standing with the City of Huntington Beach. The following pages of this narrative include current business licenses, permits, and OC Sheriff certifications for your review. EXHIBIT B 4-27- TO BE POSTED IN A CONSPICUOUS PLACE AND NOT TRANSFERABLE OR ASSIGNABLE. Business Name Business Location Business Owner(s) Business License Number Effective Date Description Expiration Date CITY OF FOUNTAIN VALLEY BUSINESS LICENSE CERTIFICATE 17981 Los Tiempos St Fountain Valley, Ca 92708-6021 ADDICTION TREATMENT CENTER GEORGE VILAGUT THE STEPHOUSE RECOVERY, INC. 17981 LOS TIEMPOS ST FOUNTAIN VALLEY, CA 92708-6021 For all inquiries regarding this license, contact HdL Business License Division at (714) 855-3982. "For Services Provided in the City of Fountain Valley, California Only" GEORGE VILAGUT Business TypeTHE STEPHOUSE RECOVERY, INC.Professional & Semi-Professional November 01, 2023 October 31, 2024 00017256 THE STEPHOUSE RECOVERY, INC.: Thank you for your payment on your City of Fountain Valley Business License. ALL CERTIFICATES MUST BE AVAILABLE FOR INSPECTION UPON REQUEST. If you have questions concerning your business license, contact the Business Support Center via email at: FountainValley@hdlgov.com or by telephone at: (714) 855-3982. Keep this portion for your license separate in case you need a replacement for any lost, stolen, or destroyed license. A fee may be charged for a replacement or duplicate license. Starting January 1, 2021, Assembly Bill 1607 requires the prevention of gender-based discrimination of business establishments. A full notice is available in English or other languages by going to: https://www.dca.ca.gov/publications/ City of Fountain Valley BUSINESS LICENSE CERTIFICATE BUSINESS LICENSING 8839 N CEDAR AVE #212 FRESNO, CA 93720-1832 Date of Issue:11/01/2023 00017256License Number: GEORGE VILAGUT THE STEPHOUSE RECOVERY, INC. 17981 LOS TIEMPOS ST FOUNTAIN VALLEY, CA 92708-6021 State License Number State Sellers Permit Number 5-28- 6-29- TO BE POSTED IN A CONSPICUOUS PLACE AND NOT TRANSFERABLE OR ASSIGNABLE. Business Name Business Location Business Owner(s) Business License Number Effective Date Description Expiration Date CITY OF FOUNTAIN VALLEY BUSINESS LICENSE CERTIFICATE 9679 Ellis Ave Fountain Valley, Ca 92708-6628 ADDICTION TREATMENT CENTER GEORGE VILAGUT THE STEPHOUSE RECOVERY, INC. 9679 ELLIS AVE FOUNTAIN VALLEY, CA 92708-6628 For all inquiries regarding this license, contact HdL Business License Division at (714) 855-3982. "For Services Provided in the City of Fountain Valley, California Only" GEORGE VILLAGUT Business TypeTHE STEPHOUSE RECOVERY, INC. Service- Personal Care March 01, 2024 February 28, 2025 00031853 THE STEPHOUSE RECOVERY, INC.: Thank you for your payment on your City of Fountain Valley Business License. ALL CERTIFICATES MUST BE AVAILABLE FOR INSPECTION UPON REQUEST. If you have questions concerning your business license, contact the Business Support Center via email at: FountainValley@hdlgov.com or by telephone at: (714) 855-3982. Keep this portion for your license separate in case you need a replacement for any lost, stolen, or destroyed license. A fee may be charged for a replacement or duplicate license. Starting January 1, 2021, Assembly Bill 1607 requires the prevention of gender-based discrimination of business establishments. A full notice is available in English or other languages by going to: https://www.dca.ca.gov/publications/ City of Fountain Valley BUSINESS LICENSE CERTIFICATE BUSINESS LICENSING 8839 N CEDAR AVE #212 FRESNO, CA 93720-1832 Date of Issue:03/01/2024 00031853License Number: GEORGE VILAGUT THE STEPHOUSE RECOVERY, INC. 9679 ELLIS AVE FOUNTAIN VALLEY, CA 92708-6628 State License Number State Sellers Permit Number 7-30- 8-31- CITY OF HUNTINGTON BEACH DEPARTMENT OF COMMUNITY DEVELOPMENT PLANNING ⧫ BUILDING ⧫ PERMIT CENTER ⧫ ECONOMIC DEVELOPMENT ⧫ HOUSING ⧫ CODE ENFORCEMENT 2000 Main Street ⧫ Huntington Beach CA 92648-2702 ⧫ www.huntingtonbeachca.gov NOTICE OF ACTION October 24, 2023 George Vilagut 356 5th Street Huntington Beach, CA 92648 APPLICATION: SPECIAL USE PERMIT NO. SUP-2023-002 FACILITY OWNER/ OPERATOR: George Vilagut, 356 5th Street, Huntington Beach CA 92648 PROPERTY OWNER: George Vilagut, 356 5th Street, Huntington Beach, CA 92648 REQUEST: To operate a Sober Living Home serving six or fewer residents. FACILITY LOCATION: 8422 Polder Circle, Huntington Beach, CA 92647 DATE OF ACTION: October 24, 2023 On Tuesday, October 24, 2023, the Community Development Department of the City of Huntington Beach took action on your application and approved your permit. The operation of the subject sober living home is subject to the requirements listed in the Huntington Beach Zoning and Subdivision Ordinance (HBZSO), Section 230.28. This Special Use Permit may not be transferred to any other person or entity. Failure to comply with the requirements listed in Section 230.28 of the HBZSO may result in the revocation of this permit. If you have any questions regarding this Notice of Action letter or the processing of your application, please contact Madalyn Welch, the city contact, at (714) 374-5353 or via email at madalyn.welch@surfcity-hb.org or the Department of Community Development at (714) 536-5271. Sincerely, Ursula Luna-Reynosa Community Development Director By: Madalyn Welch Associate Planner 9-32- 10-33- EXHIBIT C Stephouse Recovery Policies for SUP GOOD NEIGHBOR POLICY A top priority for StepHouse Recovery is to ensure that the occupants of our homes are considerate of the neighbors and respectful of the neighborhoods in which they reside. The following protocol should always be followed by clients and staff to ensure that the community and StepHouse Recovery maintain a healthy relationship. StepHouse Recovery provides contact information of our managerial staff to the bordering neighbors (located behind, to the left, to the right, as well as across the street of each recovery residence). We provide bordering neighbors with an "Introductory Letter" informing them of our presence in the community and our mission and efforts to help those in recovery make their fresh start in a safe and sober environment. "Introductory Letters" can be requested from staff. Should a neighbor contact a house manager with a complaint regarding our home or its occupants, it is the responsibility of the house manager to pass this information to Management immediately, failure to do so will result in a written warning. Management will respond to the complaint within 12 hours to let the concerned neighbor know that the complaint was received, and we will investigate and address the issue as the situation warrants. To maintain a clean presentation of the house and grounds, gardening will take place bi-weekly by a paid landscaping company. Management will also conduct outside maintenance as needed. Clients may not leave personal belongings, bicycles, trash, or other disposed of items at the front of the house. A monthly checkup by the Director will be made, and the current condition of the home and its grounds will be documented. Clients are required to abide by the StepHouse Recovery House Rules. Clients are expected to maintain an appropriate noise level and always behave appropriately. Smoking and vaping are permitted only in designated areas (posted) as outlined in the house rules. Cigarettes are to be disposed of in an appropriate manner. Clients are expected to maintain a clean environment and never litter. Staff and clients are responsible for setting trash cans out on the curb and bringing them in on the assigned trash day. Contact Information: Stephouse Recovery (888) 923-7623 info@stephouserecovery.com Orange County Healthcare Agency Monica Curran mcurran@ochca.com (714) 834-2488 or Monica Cabral MoCabral@ochca.com (714) 834-2027 11-34- INTAKE POLICY AND PROCEDURE Admission Criteria Stephouse Recovery must receive an email from the OCHCA gatekeeper. Once a client arrives, we fax the Referral form back to HCA. Intake means the initial face-to-face meeting between a Client and Stephouse Recovery staff in which specific information about the Client is gathered, including waiver of confidentiality and other required documents signed at the time of the Client's initial intake into the Recovery Residence facility. This is completed to permit disclosure of designated information about the Client to HCA, Treatment Provider, Courts, Orange County Probation Department, (OCPD), Parole Department, Public Defender, and/or District Attorney. Intake Prescreening Policy, Readmission, Intake and Discharge Criteria Policy and Procedure It is the policy of Stephouse Recovery to have every client goes through an intake process upon arrival. It is the policy of Stephouse Recovery to maintain consistent Admission, Readmission, and Intake Criteria. *If a client is deemed to need a higher level of care, Stephouse Recovery will not accept the client into the program and will refer the client back to OCHCA* Procedure All clients requesting admission are scheduled for an intake session with designated staff. The staff will conduct a face-to-face interview and is responsible for the appropriate assessment collected on the intake form and reviewed by the intake staff. Criteria to qualify for enrollment includes ▪ A willingness to continue sobriety ▪ Abstinence from drugs and alcohol for at least one month prior to admittance ▪ Successful completion of a detox and treatment program. ▪ No one who is under the influence or displaying questionable or dangerous behaviors will be admitted to Stephouse Recovery. OCHCA requires that staff are trained in Recognizing Symptoms Requiring Appropriate Referral. ▪ Residents must be capable of living independently. Should a referral be denied admission, the person will be referred back to the OC HCA Gatekeeper for more appropriate placement. During the intake process, the intake staff will perform the following functions: ▪ Review client rights ▪ Review Stephouse Recovery policies and procedures ▪ Obtain the consent and appropriate release of information CLIENT RELAPSE POLICY If a client relapses, staff will complete an incident report and notify the Program Monitor and the client’s Probation Officer. Stephouse Recovery management will decide if the client can stay in the program. If the client does stay in the program, he or she will be placed on a behavioral contract with zero tolerance for any further violation of Stephouse rules. If the client does not stay in the program, he or she will be referred by Stephouse to a different facility/program. Please see the Discharge Policy and Procedure for additional actions for relapsed clients. MOTOR VEHICLE (INCL. MOTORCYCLE) POLICY ● Clients driving a motor vehicle or motorcycle must possess and provide copies of a current California Driver's License, proof of insurance, and registration. ● Clients are not allowed to ride in the car of another client or allow another client to drive their car. ● All vehicles must be insured and properly registered, and the client must have a valid driver's license. 12-35- ● Auto repair on the premises is not permitted without prior management permission. ● Clients are allowed only the vehicle they are currently using, no additional vehicles are permitted. Vehicles are a privilege that may be revoked at any time due to non-compliance with program rules and expectations. DISCHARGE/TERMINATION POLICY Client has completed the program when they have used their maximum allotted time or reached their goals for transition. Staff will complete a Discharge Form to document the circumstances of the client leaving sober living. Clients are not required to sign the discharge form. Failure to comply with StepHouse policies signed at intake may result in a written warning or administrative termination from the program. Infractions will be documented in the client's record, and a behavioral contract will accompany the written warning. The client's Probation/Parole Officer will be notified of termination when applicable. In addition, there may be circumstances where law enforcement may be called, and legal action taken against the client. If a client discharges or is terminated from the program and does not collect personal belongings, the items will be held for seven (7) days (excluding food products) and then discarded or donated to charity. Clients terminated from the program must be sober before they enter StepHouse property. Each client should receive a housing resource guide upon discharge. Stephouse Recovery will assist discharged clients in securing safe, temporary shelter in the event of immediate discharge. Residents who have relapsed and under the influence may be transported to Be Well Orange Campus or College Hospital Costa Mesa. Cause for Termination from the Program ● If a client needs a higher level of care than provided at StepHouse Recovery. The client will be referred to OCHCA. ● The client has left the residence and no contact has been made after three (3) days (unless other arrangements have been made) ● Theft of any kind. Theft may also result in legal proceedings. ● Threatening or dangerous behavior. ● Behavior that is not conducive to recovery. Unacceptable behavior includes but is not limited to sexual activity on the premises, fighting, stealing, lying, etc. ● Confrontational behavior, harassment, and being a constant nuisance to other clients or staff. ● Continuous poor behavior and attitude toward staff or other clients. ● Positive results/refusal of urinalysis, breathalyzer, or any other drug test. Refusal to test is equivalent to a POSITIVE test. ● DRUG/ALCOHOL AND/OR PARAPHERNALIA on the premises. ● Taking or possessing prescription drugs that are prescribed to someone else. ● Vandalism or other deliberate abuse of house property. ● Sexual harassment to residents, vendors, staff, or others. ● Violating the no-smoking policy. ● Leaving after curfew without permission. ● Illegal activities of any kind. ● Violence or threats of violence. ● Weapons possession. ● Failure to sign in/out when entering or leaving the residence. This may result in a written client warning or discharge from the program as needed. ● Refusing to allow a search of personal belongings, room, or person. 13-36- In addition, clients are required to maintain an appropriate noise level. Loud noises of any kind are prohibited; please keep noises to a minimum. The first offense will result in a verbal warning and will be documented in the client's record. Repeated violations may result in discharge from the program. These causes for termination are not an exhaustive list. Stephouse Management reserves the right to consider all circumstances, behaviors, issues, etc., for appropriate action. All terminations are up to the staff’s discretion. Once a client is discharged, they are not allowed to return to the facility except to retrieve personal belongings. Arrangements to retrieve belongings should be made in advance with StepHouse Recovery staff. DISCHARGE PROCEDURES FOR STAFF Procedure A client has completed the program when they have used their maximum allotted time or reached their goals for transition. However, when a client leaves Stephouse Recovery for any reason, the staff must fax back the original Client Referral Form to the OCHCA Gatekeeper. The bottom portion of the form must include the discharge date, complete or incomplete, and the reason for leaving. Clients successfully completing the program should complete and sign an AB109 Discharge Plan form. Staff should also complete the Stephouse Recovery Discharge Form to assist in reporting information to OCHCA. No signature is required from clients who are terminated before completion. Failure to comply with Stephouse policies signed at intake may result in a written warning or termination from the program. Infractions will be documented in the client's record, and a behavioral contract will accompany the written warning. If the client is terminated, the OCHA Gatekeeper will be notified immediately via fax, and the OCHA Program Officer will be notified by email. When applicable, the client's Probation Officer and/or emergency contact will also be notified. Housing Resources shall be provided to clients regardless of completion status. In the case of homelessness, the appropriate city agency will be contacted to determine if services are available for the client. Should transportation to treatment or a shelter be necessary, Stephouse will provide. In addition, there may be circumstances where law enforcement may be called, and legal action taken against the client. If a client discharges from the program and does not collect personal belongings, the items will be held for seven (7) days (excluding food products) and then discarded or donated to charity. Clients terminated from the program must be sober before they enter Stephouse property. Each client should receive a housing resource guide upon discharge. Cause for Discharge Criteria • If a client needs a higher level of care. • The client has not returned, and no contact has been made after three (3) days. • Theft of any kind. Theft may also result in legal proceedings. • Threatening or dangerous behavior. • Behavior that is not conducive to recovery. Unacceptable behavior includes but is not limited to sexual activity on the premises, fighting, stealing, lying, etc. • Confrontational behavior, harassment, and being a constant nuisance to other clients or staff. • Continuous poor behavior and attitude toward staff or other clients. • Positive results/refusal of urinalysis, breathalyzer, or any other drug test. Refusal to test is equivalent to a POSITIVE test. • DRUG/ALCOHOL AND/OR PARAPHERNALIA on the premises. • Taking or possessing prescription drugs that are prescribed to someone else. • Vandalism or other deliberate abuse of house property. • Sexual harassment to residents, vendors, staff, or others. • Violating the no-smoking policy. • Leaving after curfew without permission. • Illegal activities of any kind. 14-37- • Violence or threats of violence. • Weapons possession. • Failure to sign in/out when entering or leaving the residence. This may result in a written client warning or discharge from the program as needed. • Refusing to allow a search of personal belongings, room, or person. In addition, clients are required to maintain an appropriate noise level. Loud noises of any kind are prohibited; please keep noises to a minimum. The first offense will result in a verbal warning and will be documented in the client's record. Repeated violations may result in discharge from the program. These causes for termination are not an exhaustive list. Stephouse Management reserves the right to consider all circumstances, behaviors, issues, etc., for appropriate action. All terminations are up to the staff’s discretion. Once a client is discharged, they are not allowed to return to the facility except to retrieve personal belongings. Arrangements to retrieve belongings should be made in advance with Stephouse Recovery staff. RECORDS MANAGEMENT AND MAINTENANCE A. Stephouse Recovery, its officers, agents, employees, and sub-contractors shall, throughout the term of the Contract Agreement, prepare, maintain, and manage records appropriate to the services provided and in accordance with the Agreement and all applicable requirements. 1. Stephouse Recovery shall maintain records that are adequate to substantiate the services for which claims are submitted for reimbursement under the Agreement and the charges thereto. Such records shall include, but not be limited to, individual patient charts and utilization review records. 2. Stephouse Recovery shall keep and maintain records that include referral and intake documents, client identification, insurance information and authorizations to share information. Additional records include client drug screening, and supporting logs as required by OCHCA. 3. Stephouse Recovery shall maintain books, records, documents, accounting procedures and practices, and other evidence sufficient to reflect properly all direct and indirect cost of whatever nature claimed to have been incurred in the performance of the Agreement and in accordance with Medicare principles of reimbursement and GAAP. 4. Stephouse Recovery shall ensure the maintenance of medical records required by §70747 through and including §70751 of the CCR, as they exist now or may hereafter be amended, the medical necessity of the service, and the quality of care provided. Records shall be maintained in accordance with §51476 of Title 22 of the CCR, as it exists now or may hereafter be amended. B. Access to client records and information is restricted by job title, individual need to know or need to complete job duties and contract requirements. Non-routine access to client records must be approved by Stephouse Director or Compliance Officer. These include, but are not limited to the following: 1. Research 2. Subpoena 3. Court Orders 4. Mandatory Reporting 5. Accreditation Surveys 6. Law Enforcement 7. Government Agencies C. Stephouse Recovery shall implement and maintain administrative, technical, and physical safeguards to ensure the privacy of PHI and prevent the intentional or unintentional use or disclosure of PHI in violation of the HIPAA, federal, and state regulations. Stephouse Recovery shall mitigate to the extent practicable, the known harmful effect of any use or 15-38- disclosure of PHI made in violation of federal or state regulations and/or OCHCA policies. D. Stephouse Recovery participant, client, and/or patient records shall be maintained securely. Stephouse Recovery shall maintain participant, client, and/or patient records and has established and implements written record management procedures. E. Stephouse Recovery shall retain all financial records for a minimum of ten (10) years from the termination of the Agreement unless a longer period is required due to legal proceedings such as litigations and/or settlement of claims. E. Stephouse Recovery shall retain all client and/or patient medical records for ten (10) years following discharge of the participant, client, and/or patient. F. Stephouse Recovery shall make records pertaining to the costs of services, participant fees, charges, billings, and revenues available at one (1) location within the limits of the OCHCA of Orange. If Stephouse Recovery is unable to meet the record location criteria above, OCHCA may provide written approval to Stephouse Recovery to maintain records in a single location, identified by Stephouse Recovery. G. Stephouse Recovery shall notify OCHCA of any PRA requests related to, or arising out of, this Agreement, within forty-eight (48) hours. Stephouse Recovery shall provide OCHCA all information that is requested by the PRA request. H. Stephouse Recovery shall ensure all HIPAA DRS requirements are met. HIPAA requires that clients, participants and/or patients be provided the right to access or receive a copy of their DRS and/or request an addendum to their records. Title 45 CFR §164.501, defines DRS as a group of records maintained by or for a covered entity that is: 1. Medical and billing records about individuals maintained by or for a covered healthcare provider. 2. The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or 3. Used, in whole or in part, by or for the covered entity to make decisions about individuals. I. Stephouse Recovery may retain client, and/or patient documentation electronically in accordance with the terms of this Agreement and common business practices. If documentation is retained electronically, Stephouse Recovery shall, in the event of an audit or site visit: 1. Have documents readily available within twenty-four (24) hour notice of a scheduled audit or site visit. 2. Provide auditor or other authorized individuals access to documents via a computer terminal. 3. Provide the auditor or other authorized individuals with a hardcopy printout of documents, if requested. J. Stephouse Recovery shall ensure compliance with requirements pertaining to the privacy and security of PII and/or PHI. Stephouse Recovery shall, upon discovery of a Breach of privacy and/or security of PII and/or PHI by Stephouse Recovery, notify federal and/or state authorities as required by law or regulation, and copy OCHCA on such notifications. K. Stephouse Recovery may be required to pay any costs associated with a Breach of privacy and/or security of PII and/or PHI, including but not limited to the costs of notification. Stephouse Recovery shall pay any and all such costs arising out of a Breach of privacy and/or security of PII and/or PHI. L. Stephouse Recovery shall make records pertaining to the costs of services, patient fees, charges, billings, and revenues available at one (1) location within the limits of the OCHCA of Orange. RECORD RETENTION POLICY Following a discharge, Stephouse Recovery shall retain all participant, client, and patient medical records for ten (10) years, except non-emancipated minors for whom records must be kept for at least one (1) year after such children have reached the age of eighteen (18) years, or for ten (10) years after the last date of service, whichever is longer. This information will also include dates of the client's entry and completion or termination from the facility, including the circumstances of their discharge. 16-39- TRANSPORTATION POLICY StepHouse Recovery shall arrange for transportation via bus vouchers, as necessary. StepHouse Recovery will also provide information regarding public transportation, how to obtain a bus pass, bus schedules, etc. If the client owns and operates a vehicle, StepHouse Recovery shall do its best to accommodate the vehicle in accordance with federal, state, and county rules and regulations. StepHouse Recovery is not responsible for transportation via clients’ cars. Choosing to ride in the car of another client or allow another client to drive your car is strongly discouraged and is done at your own risk. Clients are not permitted to drive or operate StepHouse Recovery vehicles. Clients can also use the service Veyo for non-emergency medical transportation. This service can be used for doctor’s appointments, meetings, therapy, etc. Call the number 1-833-648-7528 and mention that you are a client at StepHouse Recovery. All drivers of vehicles who are picking up or dropping off Stephouse Recovery clients must drive currently registered vehicles and hold a current driver’s license. Drivers may not impede residential traffic or block driveways and must obey all traffic laws. DRUG/ALCOHOL POLICY Alcohol, illegal drugs, or non-prescribed drug use, distribution, and/or possession are strictly prohibited. Cough syrup or mouthwash with alcohol content is prohibited. A client must have total abstinence from any mind/mood-altering chemicals and/or drugs. No paraphernalia (syringes, papers, pipes, spoons, etc.) associated with drugs on-premises. No association with any active drug or alcohol offender(s), nor frequent places where drugs are sold, used, or are accessible. Any infraction may result in the client being put on a standout*, behavioral contract, or discharged. (*Standout- A specified number of days when a client is banned from the house). DENIED ADMISSION POLICY If a client is deemed to need a higher level of care, Stephouse Recovery has the discretion not to accept the client into the program and will refer the client back to OCHCA. A client can be denied admission by Stephouse Recovery for felonious sex crimes, arson, or other violent felonies. If a client has a positive drug test at admission, Stephouse Recovery has the discretion to not accept the client into the program and will refer the client back to OCHCA. Stephouse Recovery complies with all State and Local laws and penal codes regarding registered sex offenders. A referral may be denied admission if the offender does not meet the legal requirements. EMERGENCY RESPONSE PLAN Call 911 in the event of: 1. Fire 2. Violence or a threat of violence 3. Suspicious persons hanging around premises 4. Burglary 5. A life-threatening medical situation 6. Chest pain 17-40- 7. Shortness of breath 8. Suicide attempt 9. Unconscious individual 10. Injury in which there is a broken bone or bleeding that cannot be stopped 11. Serious fall 12. Unable to wake someone 13. Ingestion of toxic chemicals or substances 14. Suspected overdose of a substance or alcohol 15. Individual out of control 16. Individual hallucinating 17. Individual having an extreme allergic reaction 18. Extreme paranoid behavior When overdose is suspected - administer Naloxone to the individual in crisis and dial 911. After a resident calls 911, they should call the house manager/management and inform them of the situation. Make sure you move to a safe place to wait for the arrival of emergency assistance. DO NOT try to move an injured person, give First Aid or CPR unless you are qualified. Upon intake, the House Manager will ensure that all residents are aware of the emergency exit routes and location of fire extinguishers for the residence. Phone numbers for the House Manager, Stephouse Recovery Management, and OC HCA Program Officers shall be kept current on the bulletin board in the common area of the residence. VISITATION POLICY StepHouse Recovery does not allow any visitation/visitors to any of the facilities. Failure to comply will result in discharge from the program and P.O. may be notified. ANY INFRACTION MAY RESULT IN BEING WRITTEN UP or TERMINATION FROM THE PROGRAM. P.O. WILL BE NOTIFIED. 18-41- 19 EXHIBIT D -42- 1 Revised August 2024 COUNTY Name MRN DOB Date StepHouse Recovery Sober Living - Intake Name: ____________________________________________ Date: _________________ Telephone: ____________________ DOB: ____________ Social Security: _______________________ Driver’s License #: _________________ Issuing State: ______ Ethnicity: ◻ American Indian or Alaska Native ◻ Asian ◻ Black or African American ◻ Hispanic ◻ Native Hawaiian or Other Pacific Islander ◻ White ◻ Other, please state: _____________________ ◻ Prefer Not to State Gender: ◻ Female ◻ Male ◻ Transgender ◻ Non-binary/non-conforming ◻ Prefer not to state Current Address: _____________________________________________________________ Last Address: ________________________________________________________________ Current Email Address: ________________________________________________________ Disabilities: __________________________________________________________________ Chronically Homeless Yes _____ No_____ History of Domestic Violence Yes _____ No_____ 20 EXHIBIT E -43- 2 Revised August 2024 Prior Incarceration Yes _____ No_____ Support System in Place Yes _____ No_____ History of Substance Abuse Yes _____ No_____ Mental Health Issues Yes _____ No_____ Have you been convicted of any sex offense in which you had to register as a sex offender under California Penal Code Section 290? ______ Yes ______ No Have you been convicted of any arson offenses - Violation of Penal Code sections, 451, 451.1, 451.5, 452, 452.1, 453, 454, 455? ______ Yes ______ No Have you been convicted of any violent felonies, as defined by Penal Code section 667.5, which involves doing bodily harm to another person? ______ Yes ______ No Are you an active member or currently participating in the criminal activities of a prison gang and or criminal street gang, as defined in Penal Code section 186.22 (f)? ______ Yes ______ No Client Signature: ________________________________________ Date: _____________ Staff Signature: _________________________________________ Date: _____________ FOR OFFICE USE ONLY Date of Entrance: ____________ Site/Unit: _____________ Room #: ______ 21-44- 3 Revised August 2024 EMERGENCY CONTACT Emergency Contact: _______________________________ Relationship: ___________________________________________ Phone Number: __________________________________ Email: __________________________________________ 22-45- 4 Revised August 2024 Employer/Volunteer/School Information You must be doing one or more of the activities listed below. Please choose one: ◻ Employed ◻ Part Time ◻ Full Time Employer: __________________________________ Occupation: _____________________ Address: ___________________________________________________________________ Telephone: _____________________ Supervisor’s Name: ___________________________ Schedule: __________________________________________________________________ ◻ Seeking Employment - Every Friday you must submit a weekly report with jobs you applied to & interviewed with. Date of last employment: __________________________________________ ◻ Attending School School: ______________________________ Location: ____________________________ Schedule: ___________________________________________________________________ ◻ Volunteer Work Volunteer Organization: ________________________________________________________ Location: ____________________________________________________________________ Grateful Hearts is a local organization where clients may volunteer. Email lgarcia@gratefulhearts.org to organize volunteer hours. Signature: ______________________________ Date: ____________________ 23-46- 5 Revised August 2024 Probation Officer Information Probation Officer/Parole Officer name: _________________________________ Address: _______________________________________________________ Phone: _________________________________________________________ ◻ I am not on probation. Client Signature: ______________________________ Date: _____________ Staff Signature: _______________________________ Date: _____________ 24-47- 6 Revised August 2024 CLIENT HEALTH SCREENING Do you currently have any of the following symptoms? Yes or No a) Fever/chills/body aches ________ b) Cough ________ c) Shortness of breath ________ d) Temperature check, must be under 100.4 degrees ________ If yes, please offer to reschedule their appointment and provide bridge medications. If the patient indicates that they are in crisis, the sick person should be offered a mask and referred to the on -duty staff. At that point, screening should be kept to a minimum to evaluate for safety. Once deemed safe to leave, they should be sent home and referred to their primary care physician or local walk-in clinic. If shortness of breath is significant, they can be sent to an emergency room, which is the BHS clinic standard already. Client Signature: __________________________________ Date: _______________ 25-48- 7 Revised August 2024 Medical History ✔ DISEASE/CONDITION DURATION COMMENTS Alcoholism Asthma Cancer Diabetes Drug Use Heart Disease High Blood Pressure Other: Other: Other: Other: Current Physician: ____________________________ Phone: _______________ Allergies: _________________________________________________________ Allergic Reaction(s): ________________________________________________ Tobacco/Nicotine Use: ______________________________________________ If a client needs help obtaining medical care, they should reach out to the administrator of StepHouse Recovery at 714.873.3032. If a client needs immediate medical assistance, they should call 911. 26-49- 8 Revised August 2024 CLIENT DRUG HISTORY Drug(s) of Choice Amount/Frequency Alcohol Amphetamines (Adderall, Concerta, Ritalin, etc.) Benzodiazepines (Ativan, Klonopin, Valium, Xanax, etc.) Cocaine Codeine Crack Cocaine Ecstasy, MDMA, Molly Fentanyl Heroin Hallucinogens (DMT, LSD, Mushrooms, Peyote, etc.) Inhalants Marijuana/THC Methamphetamines Opioid Prescriptions (Oxycontin, Percocet, Vicodin, etc.) PCP Other: Client Signature: _______________________________ Date: ____________________ 27-50- 9 Revised August 2024 PRESCRIPTION MEDICATIONS By signing below, I have read, understand, and will comply with the following policies regarding prescription medications. Failure to comply may result in a write-up, blackout, or discharge within the staff’s discretion. Failure to comply will result in the client’s P.O. being notified. ● All prescriptions and over-the-counter medications being taken must be disclosed to management upon admission. ● No legal or illegal narcotics are allowed to be brought into StepHouse Recovery Upon admission. ● Over-the-counter medications must be approved and documented by staff. ● If a client is prescribed non-narcotic psychotropic medications, the client must continue taking them as prescribed by their psychiatrist or physician to stay in the facility. ● If a prescription is renewed or discontinued, it must be reported to staff and documented in the client’s file. ● Taking or possessing prescription drugs that are prescribed to someone else is strictly prohibited. ● Abuse of medication can be considered a relapse and the client will be transferred to detox or discharged. ● In emergency situations (i.e., surgery, car accident, etc.), controlled and/or narcotic medication may be necessary and may be allowed on a case-by-case basis. Client Signature: _______________________________ Date: ____________________ 28-51- 10 Revised August 2024 PRESCRIPTION MEDICATIONS CONT. Please list any prescribed medications that you are currently taking and provide staff with pictures of your medications for your file: 1. ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ 4. ____________________________________________________________ 5. ____________________________________________________________ 6. ____________________________________________________________ Doctor Information: Name Address Phone Notes/Other Info: Client Signature: ___________________________________ Date: ____________________ 29-52- 11 Revised August 2024 STEPHOUSE RECOVERY ADMISSION AGREEMENT Applicant’s Name: ________________________ Enrollment Date: __________ To be considered for admission, prospective clients shall possess the following: a desire to stay sober, the ability to get along with others, agree to abide by all Policies and Procedures, and a willingness to work their program. StepHouse Recovery will not discriminate based on ethnic group identification, religion, age, sex, sexual preference, race, or disability pursuant to the Title IV of the Civil Rights Act of 1964 (Section 20000d, Title 42, United States Code); Section 11135 of California Government Code; and for recipients of financial assistance of the Rehabilitation Act of 1973 (Section 794. Title 29, United States Code); and Chapter 6 (Commencing with Section 10800) Division 4, Title 9 of the California Code of Regulations in accordance with all state and federal laws and regulations. Stephouse will provide assurance of provision and recognition of personal rights and the right to confidentiality as provided for in Title 42, Section 2.1 through 2.67-1, Code of Federal Regulations, effective August 1, 1975. If a client is deemed to need a higher level of care, StepHouse Recovery will deny entry of the client into any sober living facility and will suggest admission to a residential detox facility. StepHouse Recovery offers a healthy, independent, and shared living environment free from alcohol and drugs. We provide safe and supportive residential homes that encourage continued recovery from substance abuse and addiction. Food, bed linens, and cleaning supplies are also provided. Clients will be directed to an independent physician if they require medical services. Using any medical services/physician is at the client's sole discretion, and the client is responsible for paying the physician directly for any medical and pharmaceutical costs. Stephouse Recovery will also provide clients with employment and housing resource information. 30-53- 12 Revised August 2024 STEPHOUSE RECOVERY’S POLICIES AND PROCEDURES PLEASE INITIAL AFTER READING EACH SECTION: AUTHORITY POLICY StepHouse Recovery shall recognize the authority of the Orange County Probation Department (OCPD) as officers of the court and shall extend cooperation to OCPD within the constraints of state and federal laws and regulations. StepHouse Recovery shall operate in accordance with Local, State, and Federal laws and regulations. StepHouse Recovery has an open-door policy with law enforcement, probation/parole, and court services programs. All clients agree to be respectful to all. (______) Initial CLEANING POLICY Be considerate to others. Practice good hygiene by showering regularly, washing clothes and bedding regularly, and keeping personal living areas clean and orderly. Clean up after yourself; especially after using the shared common areas (bathroom, living room, patio, yards, garage areas, kitchen, fridges, etc.). All common areas in housing are to be shared and treated with respect and cleanliness. Cleaning supplies are provided to the facilities. Mandatory cleaning days will be scheduled by staff biweekly on Sundays. (______) Initial CLIENT CONFIDENTIALITY POLICY I shall respect and maintain the confidentiality of all discussions between staff and other clients in connection with group meetings where clients share personal information. I understand that I am legally prohibited from posting or sharing pictures, videos, or information about other clients, discussions, or activities online in any format (including, but not limited to email, websites, message boards, blogs, and social networking platforms). I understand that these are the conditions of my admission to StepHouse Recovery. Any breach of the Client Confidentiality Agreement may result in immediate discharge from StepHouse Recovery. 31-54- 13 Revised August 2024 I further understand that my personal file may be audited by StepHouse Recovery’s authorized personnel for the purpose of monitoring quality, performance, and compliance. All information will be kept confidential and in accordance with the Federal Confidentiality Regulations. (______) Initial CLIENT SIGN-IN/OUT POLICY – CLIENT SCHEDULES All clients must sign in/out when entering or leaving the residence. Failure to do so will result in a write -up, blackout, or discharge from the program as needed. StepHouse Recovery shall provide logs for all clients that will include the following information: ✔ Client name and signature when leaving and signature again when returning ✔ Date and time leaving the Recovery Residence facility ✔ Estimated time of return to the facility ✔ Location and telephone number where the client may be reached. StepHouse Recovery shall also receive a schedule from the client for treatment, work, school, or other activities. The client shall be required to notify StepHouse Recovery staff of any change to their schedule. The schedule is maintained on a calendar monitored by staff at each home. (______) Initial OUTPATIENT PARTICIPATION POLICY Clients who are required to participate in either an Orange County approved outpatient treatment program and/or a Day Reporting Center (DRC) must comply or be discharged. Exceptions to the mandatory participation must be approved by the county of Orange and provided to Stephouse Recovery in writing. OCHCA requires that all clients attend outpatient meetings ((SMART recovery, 12-Step program, etc.). Staff will collect client meeting logs weekly on Sunday evenings. If the client is unavailable on Sunday evening, they must arrange for staff to receive the logs before Sunday evening. Clients are required to complete meeting logs as proof of attendance, which must be signed by the client’s meeting counselor or group leader. Periodically StepHouse Recovery will contact the program where the client attends meetings, requesting attendance verification. Therefore, at the time of intake, StepHouse Recovery requires a signed release of patient information form permitting the outpatient meeting agency to share information with Stephouse. (______) Initial 32-55- 14 Revised August 2024 CURFEW/OVERNIGHT POLICY Clients must be back by curfew: Weekdays- 10:00 PM. Weekends and Holidays- 12:00 AM. All clients must follow curfews unless other arrangements have been made in advance with management (i.e., overnight pass, working past curfew, etc.). Clients must be with StepHouse Recovery for a minimum of 30 days and have no behavioral issues to qualify for an overnight pass. Approval must be requested in writing to the StepHouse office at least 48 hours in advance and is up to the staff’s discretion. Clients may obtain overnight passes for a maximum of two (2) weekends or four (4) nights per month. Leaving the house after curfew hours may be grounds for termination from the program. Curfew violators will be placed on a behavioral contract and required to pass a drug test prior to returning to housing. The client agrees that they are subject to discharge if they leave StepHouse Recovery overnight without a pass. (______) Initial DISCHARGE/TERMINATION POLICY Client has completed the program when they have used their maximum allotted time or reached their goals for transition. Staff will complete a Discharge Form to document the circumstances of the client leaving sober living. Clients are not required to sign the discharge form. Failure to comply with StepHouse policies signed at intake may result in a written warning or administrative termination from the program. Infractions will be documented in the client's record, and a behavioral contract will accompany the written warning. The client's Probation/Parole Officer will be notified of termination when applicable. In addition, there may be circumstances where law enforcement may be called, and legal action taken against the client. If a client discharges or is terminated from the program and does not collect personal belongings, the items will be held for seven (7) days (excluding food products) and then discarded or donated to charity. Clients terminated from the program must be sober before they enter StepHouse property. Each client should receive a housing resource guide upon discharge. Stephouse Recovery will assist discharged clients in securing safe, temporary shelter in the event of immediate discharge. Residents who have relapsed and under the influence may be transported to Be Well Orange Campus or College Hospital Costa Mesa. Cause for Termination from the Program ● If a client needs a higher level of care than provided at StepHouse Recovery. The client will be referred to OCHCA. 33-56- 15 Revised August 2024 ● The client has left the residence and no contact has been made after three (3) days (unless other arrangements have been made) ● Theft of any kind. Theft may also result in legal proceedings. ● Threatening or dangerous behavior. ● Behavior that is not conducive to recovery. Unacceptable behavior includes but is not limited to sexual activity on the premises, fighting, stealing, lying, etc. ● Confrontational behavior, harassment, and being a constant nuisance to other clients or staff. ● Continuous poor behavior and attitude toward staff or other clients. ● Positive results/refusal of urinalysis, breathalyzer, or any other drug test. Refusal to test is equivalent to a POSITIVE test. ● DRUG/ALCOHOL AND/OR PARAPHERNALIA on the premises. ● Taking or possessing prescription drugs that are prescribed to someone else. ● Vandalism or other deliberate abuse of house property. ● Sexual harassment to residents, vendors, staff, or others. ● Violating the no-smoking policy. ● Leaving after curfew without permission. ● Illegal activities of any kind. ● Violence or threats of violence. ● Weapons possession. ● Failure to sign in/out when entering or leaving the residence. This may result in a written client warning or discharge from the program as needed. ● Refusing to allow a search of personal belongings, room, or person. In addition, clients are required to maintain an appropriate noise level. Loud noises of any kind are prohibited; please keep noises to a minimum. The first offense will result in a verbal warning and will be documented in the client's record. Repeated violations may result in discharge from the program. These causes for termination are not an exhaustive list. Stephouse Management reserves the right to consider all circumstances, behaviors, issues, etc., for appropriate action. All terminations are up to the staff’s discretion. Once a client is discharged, they are not allowed to return to the facility except to retrieve personal belongings. Arrangements to retrieve belongings should be made in advance with StepHouse Recovery staff. (______) Initial DISCRETION POLICY The client understands that they are entering independent sober living. Privacy is limited and space is shared. Stephouse Recovery staff will conduct bed checks and will be entering bedrooms regularly. StepHouse Recovery staff reserves the right to interpret and apply the rules to meet the needs of each client effectively and within reason. Staff will use their best judgment with events and circumstances as they occur. Stephouse Management reserves the right to change or make additions to StepHouse Recovery Policies and Procedures at any time. It is within StepHouse Recovery’s discretion to make amendments or modifications to any of the following: 34-57- 16 Revised August 2024 ● Rules and Regulations ● Policies ● Room Assignments ● Food Requirements ● Schedules ● Supervision ● Chore Assignments ● Testing ● Discharge Clients who violate any StepHouse Recovery Policies or Procedures agree to the decisions and consequences deemed necessary by the staff. (______) Initial DRUG/ALCOHOL POLICY Alcohol, illegal drugs, or non-prescribed drug use, distribution, and/or possession are strictly prohibited. Cough syrup or mouthwash with alcohol content is prohibited. A client must have total abstinence from any mind/mood- altering chemicals and/or drugs. No paraphernalia (syringes, papers, pipes, spoons, etc.) associated with drugs on-premises. No association with any active drug or alcohol offender(s), nor frequent places where drugs are sold, used, or are accessible. Any infraction may result in the client being put on a standout*, behavioral contract, or discharged. (*Standout- A specified number of days when a client is banned from the house). (______) Initial SUPPORT STAFF Staff is responsible for the supervision of all clients residing in the facility. Staff shall be responsible for ensuring the safety of the buildings and grounds and maintaining compliance of clients and staff with facility rules. Whenever StepHouse Recovery Staff is not present at the facility, a designated facility staff person shall be on-call to respond and arrive at the facility. StepHouse Recovery shall post the contact telephone number of designated on-call staff. The staff will randomly be on sight at the facility to perform UAs/breathalyzers and conduct random searches of the client rooms, personal property, and belongings. (______) Initial 35-58- 17 Revised August 2024 EMPLOYMENT/SCHOOL/VOLUNTEERING POLICY StepHouse Recovery requires all clients to be employed, seeking employment, attending school or volunteering during the duration of their program. Verification of employment, interviews, applications, or volunteer hours is required weekly. Proof of school enrollment is also required. Failure to comply with this policy can result in discharge from the program. (______) Initial GOOD NEIGHBOR POLICY A top priority for StepHouse Recovery is to ensure that the occupants of our homes are considerate of the neighbors and respectful of the neighborhoods in which they reside. The following protocol should always be followed by clients and staff to ensure that the community and StepHouse Recovery maintain a healthy relationship. StepHouse Recovery provides contact information of our managerial staff to the bordering neighbors (located behind, to the left, to the right, as well as across the street of each recovery residence). We provide bordering neighbors with an "Introductory Letter" informing them of our presence in the community and our mission and efforts to help those in recovery make their fresh start in a safe and sober environment. "Introductory Letters" can be requested from staff. Should a neighbor contact a house manager with a complaint regarding our home or its occupants, it is the responsibility of the house manager to pass this information to Management immediately, failure to do so will result in a written warning. Management will respond to the complaint within 12 hours to let the concerned neighbor know that the complaint was received, and we will investigate and address the issue as the situation warrants. To maintain a clean presentation of the house and grounds, gardening will take place bi-weekly by a paid landscaping company. Management will also conduct outside maintenance as needed. Clients may not leave personal belongings, bicycles, trash, or other disposed of items at the front of the house. A monthly checkup by the Director will be made, and the current condition of the home and its grounds will be documented. Clients are required to abide by the StepHouse Recovery House Rules. Clients are expected to maintain an appropriate noise level and always behave appropriately. Smoking and vaping are permitted only in designated areas (posted) as outlined in the house rules. Cigarettes are to be disposed of in an appropriate manner. Clients are expected to maintain a clean environment and never litter. Staff and clients are responsible for setting trash cans out on the curb and bringing them in on the assigned trash day. (______) Initial Contact Information: Stephouse Recovery (888) 923-7623 info@stephouserecovery.com Orange County Healthcare Agency Monica Curran mcurran@ochca.com (714) 834-2488 or Monica Cabral MoCabral@ochca.com (714) 834-2027 36-59- 18 Revised August 2024 HOUSE RULES POLICY Facility ● Accept the facility “as is”. ● The client understands they reside in a congregate housing situation, not an exclusive unit or space. ● Become familiarized with escape routes, safe gathering locations, and the need for a safe location headcount. ● It is encouraged for clients not to bring anything of high value to the facility or to keep it on their person otherwise. StepHouse Recovery is not responsible for lost, stolen, or damaged property. Clients bringing items of monetary or sentimental value to the facility are doing so at their own risk. ● No personal refrigerators, microwaves, coffee pots, heaters, furniture, candles, or excessive property is allowed. ● Moving rooms: ○ Clients may request to move rooms but are only allowed to move with permission of staff ■ Decisions will be based on seniority, behavioral assessment, and availability ○ Client must clean room previously occupied before moving. ○ Staff may need to move clients based on necessity. Changing a client’s room assignment is at the staff discretion. ● House meetings are scheduled by management on a need-be basis. If the client is unable to attend because of work conflicts, a manager must be notified. ● Laundry detergent/supplies and toiletries are not provided for client use. ● Internet Wi-Fi is provided at each location. Client Conduct ● No drugs, alcohol, and/or paraphernalia allow on house premises. ● All medications, including over the counter, must be held and dispensed by the clients themselves. ● Do not enter other clients’ rooms. Clients may only enter their own room and are not allowed to enter another client's bedroom. ● Clients are not allowed to fraternize with other clients. ● Do not share rental agreement information with other clients. ● All overnight passes must be requested for approval by Thursday of each week. ● Client agrees that if they leave StepHouse Recovery for an overnight without a "pass" they are subject to discharge. Personal belongings will only be held for seven (7) days (excluding food products) and then discarded or donated to charity. ● NO PETS- Pets of any kind are not permitted. ● Clients are expected to rise in the morning at a reasonable time to ensure they are dressed, bed made, immediate area cleaned, and house chores completed by 11 am daily. ● Assigned chores must be completed daily. ● Before leaving the house, chores must be completed, the bed must be made, and the room must be tidy. If clients have school/work/volunteering before the "11 am Chore Check", they must complete all household responsibilities before leaving. ● All clients must wear appropriate attire when in shared areas of the facility and/or in the presence of other residents and staff. Appropriate attire includes shirts and pants/shorts, and dresses. ● CURFEW, clients must be in the house by 10 PM on weekdays and 11 PM on weekends and holidays. ● Be considerate to others. Keep music and television audio so as not to disturb other clients. Pick up after yourself, leaving microwaves, common areas, and bathrooms clean for the next person. 37-60- 19 Revised August 2024 ● Shower daily, maintain personal hygiene, and wash your clothes regularly. ● Bedding must be washed weekly. ● NO SMOKING/VAPING inside of or in front of the house. SMOKING/VAPING is only permitted in designated areas. ● DO NOT LEAVE BURNING CIGARETTES UNATTENDED. ● Empty ashtrays as needed. ● Clients agree not to have any contact with ex-clients that have been discharged due to relapse or behavioral infractions. ● NO STEALING! Respect others' property. Theft is cause for immediate discharge and may result in legal proceedings. ● DO NOT TOUCH THE MAIL. The operations coordinator is the only person allowed to bring the mail in from the mailbox. ● All clients must attend at least five 12-Step meetings and scheduled house solutions meetings. ● Threatening or dangerous behavior and/or deliberate abuse of house property will be cause for immediate discharge and may result in legal proceedings. ● Sexual harassment is strictly prohibited and will result in automatic discharge from the program. The client’s Parole/Probation Officer and law enforcement will be notified. ● Clients must notify staff of any communicable disease. ● If you see something, say something. The purpose of sober living is to provide a supportive environment free from alcohol and drugs. Clients play a vital role in keeping each other safe and sober. Staff should be informed of threatening or dangerous behaviors of others, drug or alcohol use, housemates’ lack of participation in house chores, etc. ● In the event of an emergency dial 911. Staff should also immediately be notified. Daily Structured Activities Clients are required to engage in daily activities that should be discussed with their outpatient provider. Clients will be assigned household duties, including but not limited to house cleaning and basic household operations. Assigned duties must be completed daily. The client agrees to work on a program of recovery to better their lives in the form of their choosing. StepHouse Recovery highly recommends attending celebrate recovery, parenting classes, life skill classes, private counseling, and many other community-based organizations to better themselves. The client agrees and understands that a condition for being at StepHouse Recovery is to be gainfully employed, actively seeking work, in treatment, attending school, or other activities to enhance the client’s future. Staff will provide resources, assistance, and support for clients to find work, register for school, attend appropriate self - help program meetings, and volunteer in the community. (______) Initial MAIL AND PACKAGE DELIVERY POLICY StepHouse Recovery and staff are not responsible nor liable for mail or packages that clients choose to have delivered to a recovery residence. Do not open any packages not addressed to you. (______) Initial 38-61- 20 Revised August 2024 MEALS/FOOD POLICY StepHouse Recovery will provide food during the week. It is the client’s decision on whether they wish to consume the food provided. Clients are not allowed to keep any food in their rooms. All food must be kept in the kitchen or designated pantry space. Only water bottles are allowed in clients’ rooms. Clients are required to clean up after themselves. Personal items, laundry, towels, and the like should not be left in the common areas of the house. Do not leave dishes in the sink or any other areas of the house, including rooms. Clean and stow dishes, utensils, and cookware in their allocated spaces. Clean the counters and stove after use. Clean the microwave as needed, especially if you spill something. Food logs must be filled out on Sunday for the week prior. (______) Initial MOTOR VEHICLE (INCL. MOTORCYCLE) POLICY ● Clients driving a motor vehicle or motorcycle must possess and provide copies of a current California Driver's License, proof of insurance, and registration. ● Clients are not allowed to ride in the car of another client or allow another client to drive their car. ● Clients who have their vehicles must have prior approval from the program director to drive their vehicles. All vehicles must be insured and properly registered, and the client must have a valid driver's license. ● Auto repair on the premises is not permitted without prior management permission. *Vehicles are a privilege that may be revoked at any time due to non-compliance with program rules and expectations. * (______) Initial NONDISCRIMINATION POLICY StepHouse Recovery does not to discriminate on the basis of race, color, national origin, religion, sex, or mental or physical disabilities, pursuant to Title VI of the Civil Rights Act of 1964 (Section 2000d, Title 42, United States Code), the Rehabilitation Act of 1973 (Section 794, Title 29, United States Code); the Americans with Disabilities Act of 1990 (Section 12132, Title 42, United States Code); Section 11135 of the California Government Code; and Chapter 6 (commencing with Section 10800), Division 4, Title 9 of the California Code of Regulations. Any person who believes they or someone else has been subjected to discrimination based on race, national origin, sex, age, or disability may file a grievance under the following procedure. It is against the law for StepHouse Recovery to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. This policy applies to employees, contractors, vendors, clients, and all who interact with Stephouse Recovery. (______) Initial 39-62- 21 Revised August 2024 OPIOID OVERDOSE EMERGENCY TREATMENT POLICY StepHouse Recovery shall have available at each program site, at minimum, one Naloxone (Narcan) Nasal Spray for the treatment of known or suspected opioid overdose. In case of suspected opioid overdose, staff may administer Naloxone (Narcan) Nasal Spray and then call 911. Clients will also be shown how to administer Naloxone. **Note: Naloxone is the generic name of Narcan. Narcan is the brand name of Naloxone. (______) Initial PROPERTY DAMAGE POLICY The client agrees not to damage the facility, which includes the outside perimeter. Client agrees not to damage any property belonging to StepHouse Recovery which includes but is not limited to transport vehicles, appliances, and furniture. The client agrees to return any items to the facility before discharge, including linens, blankets, and towels. The client agrees if there is damage that cannot reasonably be traced back to a particular person, the cost of the damage will be shared equally among all the housemates. The client agrees to be financially responsible for all damage caused by them in any of the StepHouse Recovery facilities and transport vehicles. (______) Initial DRUG & ALCOHOL SCREENING POLICY Alcohol, illegal drug, or non-prescribed drug use or possession by clients or staff is strictly prohibited. Cough syrup with alcohol content is prohibited for client safety and sobriety. ALL CLIENTS MAY BE SUBJECT TO RANDOM DRUG SCREENS, BREATHALYZER TESTS AND ROOM SEARCHES. ● StepHouse shall perform random drug and/or alcohol testing on clients suspected of using substances AND at a minimum of one (1) time per month. ● All urine specimen collection shall be observed by same-sex staff. The result of the screening will be documented in the client's record. ● Clients are not allowed to open tests by themselves. Staff will open the tests and then give them to clients. ● If a test is unclear or possible contamination is suspected, the client will have to re-test within 1.5 hours after the first test was administered. 40-63- 22 Revised August 2024 If a client refuses a search or test or drugs or alcohol are found or detected, StepHouse Recovery will notify the client's probation officer (within one business day), and discharge from the program may result. Refusal to test is equivalent to a POSITIVE test. ** REMINDER** UNDER NO CIRCUMSTANCES SHALL A CLIENT WHO IS UNDER THE INFLUENCE BE ALLOWED IN THE HOUSE. If a client is found to be under the influence, management shall pack the client's property for retrieval at a later time. When the client is no longer under the influence, he can arrange to retrieve personal property with staff. The client’s property will be held for seven (7) days before StepHouse Recovery donates the items to charity. (______) Initial SMOKING POLICY Smoking, (including electronic cigarettes) is prohibited within the facilities; the use of tobacco and tobacco products on facility premises is allowed in the backyard or parking lot. 1. Smoking and/or vaping is prohibited in any enclosed area of StepHouse Recovery's facilities. 2. Cigarettes must be completely extinguished in receptacles or metal containers to reduce fire risk. 3. Any client violating the no-smoking policy may be discharged from the program. 4. A self-audit of the no-smoking policy will be implemented, and any violation should be reported by staff in an incident report. A monthly Health and Safety audit will be conducted to see if the no- smoking policy is being adhered to. -NO SMOKING/VAPING INSIDE OF OR IN FRONT OF THE HOUSE. SMOKING/VAPING is only permitted in designated areas. -DO NOT LEAVE BURNING CIGARETTES UNATTENDED. (______) Initial TRANSGENDER & GENDER IDENTITY POLICY StepHouse Recovery will not discriminate against ethnic group identification, religion, age, gender identification, sexual preferences, race, or disability. StepHouse Recovery will make every effort to ensure that all needs of transgender and non-cisgender persons are accommodated. We are committed to our clients feeling safe, supported, and comfortable. StepHouse Recovery is committed to maintaining client information in strict confidence. No client information is ever shared with other clients, including gender orientation. 41-64- 23 Revised August 2024 Transgender and non-cisgender clients are subject to the same drug/alcohol screening policy. A staff of the same gender the client has identified with will be in the room to observe urine specimen collection. (______) Initial GENDER-ORIENTED FACILITY POLICY StepHouse Recovery will accommodate clients according to their gender identity. Those clients identifying as male, and female will be housed in separate residences accordingly. (______) Initial TRANSPORTATION POLICY StepHouse Recovery shall arrange for transportation via bus vouchers, as necessary. StepHouse Recovery will also provide information regarding public transportation, how to obtain a bus pass, bus schedules, etc. If the client owns and operates a vehicle, StepHouse Recovery shall do its best to accommodate the vehicle in accordance with federal, state, and county rules and regulations. StepHouse Recovery is not responsible for transportation via clients’ cars. Choosing to ride in the car of another client or allow another client to drive your car is strongly discouraged and is done at your own risk. Clients are not permitted to drive or operate StepHouse Recovery vehicles. Clients can also use the service Veyo for non-emergency medical transportation. This service can be used for doctor’s appointments, meetings, therapy, etc. Call the number 1-833-648-7528 and mention that you are a client at StepHouse Recovery. (______) Initial VISITATION POLICY StepHouse Recovery does not allow any visitation/visitors in any of the facilities. Failure to comply will result in discharge from the program and P.O. may be notified. ANY INFRACTION MAY RESULT IN BEING WRITTEN UP or TERMINATION FROM THE PROGRAM. P.O. WILL BE NOTIFIED. (______) Initial 42-65- 24 Revised August 2024 NO RESPONSIBILITY CLAUSE Stephouse Recovery assumes no responsibility for the client’s personal property. Stephouse is released from all liability for any loss or damage to any and all personal property. Personal property includes but is not limited to vehicles, valuables, money, jewelry, eyeglasses, hearing aids, documents, electronic devices (i.e., computers, game consoles, and tablets), and mobile devices. Clients are advised to minimize the personal property brought into residential recovery homes. All items brought to a Stephouse Recovery home are done at the client’s own risk. Locks are not permitted on bedroom doors, and there are no exceptions to this rule. The client agrees to hold harmless The StepHouse Recovery, Inc, the property owners, and any and all Service Providers/Contractors against any and all claims, demands, suits, or loss. (______) Initial By signing below, you confirm that you have read and agree to all terms in this StepHouse Recovery Admission Agreement. Client Name: _____________________________________ Date: ____________ Client Signature: __________________________________________________ Staff Name: _____________________________________ Date: ____________ Staff Signature: ____________________________________________________ 43-66- 25 Revised August 2024 44-67- 26 Revised August 2024 I acknowledge that I have read and understand the procedures for administering NARCAN. A copy of this information will be provided for you to keep in the welcome packet. Client Name: ______________________________________________ Client Signature: ___________________________________________ Date: ______________________ 45-68- 27 Revised August 2024 (AB 109) SOBER LIVING- Client Sobriety and Treatment History I have been sober since: ____________________________________________ I have been at the following treatment programs and/or sober living facilities: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________ I am currently participating in the outpatient treatment program/or Probation DRC (Probation Reporting Center) at: ______________________________________ (TO BE FILLED OUT BY STAFF) Notations regarding how Sober Living may assist the client in implementing his/her sobriety- related plan recommendations: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _________________________________________________ Client Signature: _______________________________ Date: _______________ Staff Signature: _______________________________ Date: _______________ 46-69- 28 Revised August 2024 HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION to HCA and Orange County Probation Client Last Name: Client First Name: Date of Birth: SSN (last 4 digits) Email: Phone Number: Address: City: State: Zip: I ____________________________________________________________ do hereby authorize Client Name _______________Stephouse Recovery, Inc. ______________________________________________ Name of Agency/Provider ___9679 Ellis Ave., Fountain Valley, CA 92708_______________(714) 394-3494______________________ Address Phone Number to release my protected health information to Orange County Health Care Agency 405 W 5th Street, Santa Ana CA 92701 (855) 886-54000 And Orange County Probation Department Purpose of this authorization: ◻ Patient Request ■ Continuity of Care/Treatment ◻ Insurance ■ Requested by Legal Authority ◻ Other: ________________________________________________________ Information that can be released (check all that apply): ■ Medical Records 47-70- 29 Revised August 2024 ■ Summary of Treatment ■ Outpatient Meeting Attendance Records ◻ Other, please specify: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Types of records to be released: ■ Complete Records retained by Stephouse Recovery (including, but not limited to office notes, face sheets, history, physical, consultations, inpatient, outpatient, and emergency room treatment, test results, progress notes, social worker records, clinic records, and the like). Alcohol, Drug and/or Substance Abuse Records and Mental Health Records are excluded from this section. See below to authorize release of Alcohol, Drug and/or Substance Abuse Records and Mental Health Records. ◻ Other, please specify: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Client initials and date range of records to be released are required below for the use or release of the following types of sensitive information: Please initial on the line provided. Dates are required, “date from” will be date of admission. ___ Alcohol, Drug or Substance Abuse Records Date from: __________ Date To: __________ ___ Mental Health Records Date from: __________ Date To: __________ I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I have read the contents of this form. I understand, agree, and allow the above-named Agency/Provider to release my information as I have stated above. I also understand that signing this form is voluntary and treatment, payment, or eligibility for benefits will not be affected if I do not sign this authorization. I have the right to revoke this authorization at any time by providing written notice to Stephouse Recovery at 9679 Ellis 48-71- 30 Revised August 2024 Ave. Fountain Valley, CA 92708. The revocation will not affect disclosures that Stephouse Recovery has already taken action in reliance on the authorization. Information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer be protected by federal privacy law (HIPAA). Applicable State or other federal law may require the recipient to obtain your written authorization before re-disclosure unless otherwise permitted by such laws. I am entitled to a copy of this form. A copy of the original authorization is valid. This authorization expires three years from the date of my discharge from Stephouse Recovery. Anticipated Date of Discharge: ___________________ Client Signature: _______________________________ Date: _______________ Completed by Stephouse Recovery Staff: Printed Name: ___________________________________ Signature: ______________________________________ Date: ______________________ 49-72- 31 Revised August 2024 HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION Outpatient Meeting Provider Client Last Name: Client First Name: Date of Birth: SSN (last 4 digits) Email: Phone Number: Address: City: State: Zip: I ____________________________________________________________ do hereby authorize Client Name __________________________________ ___________________________________________________ Name of Agency/Provider _______________________________________________________________________________________ Address Phone Number to release my protected health information to to release my protected health information to Stephouse Recovery 9679 Ellis Ave. Fountain Valley CA (714) 394-3494 Purpose of this authorization: ◻ Patient Request ◻ Continuity of Care/Treatment ◻ Insurance ◻ Requested by Legal Authority ■ Other: __Proof of meeting attendance __________________________________________ 50-73- 32 Revised August 2024 Information that can be released (check all that apply): ◻ Medical Records ◻ Summary of Treatment ■ Outpatient Meeting Attendance Records ◻ Other, please specify: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Types of records to be released: ◻ Complete Records retained by Stephouse Recovery (including, but not limited to office notes, face sheets, history, physical, consultations, inpatient, outpatient, and emergency room treatment, test results, progress notes, social worker records, clinic records, and the like). Alcohol, Drug and/or Substance Abuse Records and Mental Health Records are excluded from this section. See below to authorize release of Alcohol, Drug and/or Substance Abuse Records and Mental Health Records. ■ Other, please specify: _______Meeting Attendance Only___________________________________ Client initials and date range of records to be released are required below for the use or release of the following types of sensitive information: Please initial on the line provided. Dates are required. ----- NOT APPLICABLE FOR THIS REQUEST ___ Alcohol, Drug or Substance Abuse Records Date from: __________ Date To: __________ ___ Mental Health Records Date from: __________ Date To: __________ I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I have read the contents of this form. I understand, agree, and allow the above-named Agency/Provider to release my information as I have stated above. I also understand that signing this form is voluntary and treatment, payment, or eligibility for benefits will not be affected if I do not sign this authorization. I have the right to revoke this authorization at any time by providing written notice to Stephouse Recovery at 9679 Ellis Ave. Fountain Valley, CA 92708. The revocation will not affect disclosures that Stephouse Recovery has 51-74- 33 Revised August 2024 already taken action in reliance on the authorization. Information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer be protected by federal privacy law (HIPAA). Applicable State or other federal law may require the recipient to obtain your written authorization before re-disclosure unless otherwise permitted by such laws. I am entitled to a copy of this form. A copy of the original authorization is valid. This authorization expires three years from the date of my discharge from Stephouse Recovery. Anticipated Date of Discharge: ___________________ Client Signature: _______________________________ Date: _______________ Completed by Stephouse Recovery Staff: Printed Name: ___________________________________ Signature: ______________________________________ Date: ______________________ 52-75- 34 Revised August 2024 Notice of Privacy Practices Dear Stephouse Client: Your medical and behavioral health treatment information and records are personal and private. Stephouse Recovery is committed to protecting your personal health information, also known as Protected Health Information or PHI. We are required by Federal and State laws to protect the privacy of your medical and behavioral health information. We have developed and implemented policies, procedures, and safeguards in alignment with the HIPAA Security Rule and HITECH Act of 2009 to ensure the security, confidentiality, integrity, and availability of all PHI Stephouse creates, receive s, maintains, or transmits from improper use and disclosure. Stephouse provides ongoing training to employees and outside contractors to ensure compliance with all HIPAA privacy and confidentiality regulations. If you wish to allow Stephouse Recovery to share your information with family, partners, or other persons or entities, we mus t have a release of information, signed by you, on file. We are required by law to provide you with this Notice of our legal duties and privacy practices with respect to your medical and behavioral health information. If you have any questions and/or would like additional information, you may contact Stephouse Management at (714) 394 - 3494. How We May Use and Disclose Your Protected Health Information The uses and disclosures of your protected health information are below. Use and disclosure of substance and/or alcohol use disorder information will be discussed separately. 1. Coordination of care. We may use and disclose your protected health information to provide care coordination or to direct or recommend a higher level of care and any related services, such as referral to treatment and detox centers. We may also disclose your health information to personnel at the Orange County Health Care Agency (OCHCA) or community resources and providers who may be treating you or involved in your care. 2. Payment. We may use or disclose your protected health information to determine the OCHCA or your medical insurance’s responsibility to pay for or to permit us to bill and collect payment for the services that we provide to you. 3. Sober Living Operations. We may use and disclose your protected health information to support the business activities of Stephouse Recovery Inc. We may disclose your health information to other staff or business associates who perform billing, consulting, auditing, licensing, accreditation, and other services for Stephouse Recovery. 4. Required by Law. We may use and disclose your protected health information when required by Federal, State, or local law. 5. Business Associates. We may contract with business associates to perform certain functions or activities on our behalf, such as payment, business operations, lab tests, and other services. We release the minimum amount of PHI necessary for the business associate to perform the identified services. We require business associates to safeguard your information appropriately. Examples of business associates include contractors, billing companies, outsourced laboratories, and electronic medical records vendors. 6. Victims of Abuse, Neglect, or Domestic Violence. We may disclose your protected health information to other government agencies to report suspected abuse, neglect, or domestic violence. We will only disclose this information if you agree, if the law requires us to, or when it is necessary to protect someone from serious harm. 7. Lawsuits and Legal Actions. We may use and disclose your protected health information in response to a court or administrative order, certain subpoenas, or other legal process. We may also use and disclose PHI to the extent permitted by law without your authorization, such as defending against a lawsuit or arbitration. 53-76- 35 Revised August 2024 8. Law Enforcement. We may disclose your protected health information to authorized officials such as the police, sheriff, or FBI for law enforcement purposes and in response to legal processes, such as a search warrant or court order. 9. Coroners, Medical Examiners, and Funeral Directors. We may disclose your protected health information to funeral directors, coroners, and medical examiners to permit body identification, determine what caused the death, or for other official duties. 10. To Stop a Serious Threat to Health or Safety. We may use or disclose your protected health information if we believe it is necessary to avoid or lessen a serious threat to your health or safety or to someone else’s. 11. Military Activity and National Security. We may use or disclose the PHI of armed forces personnel to the applicable military authorities when they believe it is necessary to carry out military missions properly. We may also disclose your PHI to authorized federal officials as necessary for national security and intelligence activities or for the protection of the president and other government officials and dignitaries. 12. Identity Verification. We may photograph you for identification purposes. Your photo may be stored in your Stephouse Recovery Chart. You may decline to have your photograph taken. 13. Electronic Health Records. We may use an electronic health record to store and retrieve your health information. We may also receive information about you from providers in the community who are involved with your care by using shared databases or health information exchanges. 14. Communication with Family and Others When you are Present. Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell us and we won’t discuss your PHI while that person is present. 15. Communication with Family and Others When you are Not Present. There may be times when it is necessary to disclose your PHI to a family member or others involved in your care because there is an emergency or you lack the decision-making capacity to agree or object. In those instances, we will use our professional judgment to determine if disclosing your PHI is in your best interest. If so, we will limit the disclosure to the PHI that is directly relevant to the person’s involvement with your health care. Uses and Disclosures of Your Protected Health Information Requiring Your Written Authorizations We will obtain your written permission through a signed release of information form for the uses and disclosures of your PHI not covered by this Notice. You may revoke any release of information by submitting a request in writing at any time and we will stop disclosing PHI about you to the indicated party(s). Any disclosures made prior to the revocation are not affected by the revocation. Uses and Disclosures of Your Substance and Alcohol Use Disorder Records The confidentiality of your substance and alcohol use disorder records is protected by 42 USC 290dd -2 and the Department of Health and Human Services (HHS) regulations at 42 CFR Part 2 – Confidentiality of Substance Use Disorder Patient Records. Generally, we are not allowed to disclose your participation in the program or identify you as having an alcohol or drug abuse problem to an outside person unless: 1) You consent in writing. 2) The disclosure is to prevent multiple 42 CFR Part 2 program enrollments. 3) The disclosure is allowed by a court order. 4) The disclosure is made to medical personnel to the extent necessary to meet a legitimate medical emergency. 5) The disclosure is made for certain audit and/or evaluation purposes. 54-77- 36 Revised August 2024 If you believe that the privacy of your information protected by 42 USC 290dd -2 and 42 CFR Part 2 has been violated, you may contact the U.S. Attorney’s Office, Central District of California, Santa Ana Branch Office at 411 W. Fourth Street, Suite 80 00, Santa Ana, CA 92701 or by phone at (855) 898-3957. Your Rights Regarding Your Protected Health Information 1. Right to View and Copy Your PHI. Subject to certain exceptions, you have the right to view or get a copy of your protected health information that we maintain in records relating to received services or payment for services. Your request must be submitted in writing and a fee may be charged for the costs of copying, mailing, and for any other supplies used in fulfilling your request. In limited situations, we may refuse any requests to see or receive copies of your records. If denied, we will tell you why in writing and explain your right to have our denial reviewed. 2. Right to View and Copy Laboratory Test Results. You have the right to view and copy protected health information consisting of your completed laboratory test results obtained by Stephouse Recovery. A request must be submitted in writing and a fee may be charged for the costs of copying, mailing, and any other supplies used to fulfill your request. 3. Right to Request an Amendment You have the right to request that we correct or add to your record if you believe there is a mistake in your PHI or that important information is missing. The request must be in writing; explain what corrections or additions you are requesting and the reasons the corrections or additions should be made. We may deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if: ▪ The information in your record is correct and accurate. ▪ We did not create the information in your record, or the person who created it is no longer available to make the amendment. ▪ The information is not part of the records you are permitted to view and copy. If we deny your request for amendment, we will tell you why and explain your right to file a written statement of appeal in response to our decision. 4. Right to an Accounting of Disclosures You have the right to request a list of our disclosures of your PHI. The request must be made in writing. To request an accounting, please contact us at Stephouse Recovery, 9679 Ellis Ave. Fountain Valley, 92708, or by email at info@stephouserecovery.com. A fee may be charged for copying, mailing, and any other supplies used in fulfilling your request. The list will not include the following disclosures: ▪ Those that you provided signed authorization for. ▪ To carry out payment and health care operations. ▪ To parole officers, probation officers, or other law enforcement as required. ▪ Not covered by the right to an accounting. 5. Right to Request Restrictions on Uses and Disclosures of your PHI You have the right to request a restriction or limitation on how we use or disclose your PHI under certain circumstances. Restrictions or limitations can be discussed with Stephouse Recovery Management. We are not required to agree to your request in every situation, particularly when you do not fully pay for services. 6. Right to Request Confidential Communications You have the right to request how we communicate with you to preserve your privacy. Please inform Stephouse Management if you prefer a specific form of communication; for example, if you do not wish to receive text messages. 7. Right to Revoke Releases of Information You have the right to take back or revoke your written authorization to use and disclose your PHI at any time. You must let us know of your revocation in writing. Please note that we cannot take back any information already used or shared while the authorization was valid. 55-78- 37 Revised August 2024 8. Right to a Paper Copy of this Notice 9. Notification of a Breach of PHI 10. Right to File a Complaint You have the right to file a complaint with Stephouse Recovery by writing to us at 9679 Ellis Ave., Fountain Valley, CA 92708. You also have the right to file a complaint directly to the Secretary of the United States Department of Health and Human Services (DHHS) at DHHS, Region IX Office for Civil Rights, 90 7th Street, Suite 4-100, San Francisco, CA 94103, or call (800) 368-1019, TDD (800) 537-7697. The complaint must be filed in writing and sent by mail, fax, or electronically by e-mail and within 180 days of when you found out the violation occurred. 56-79- 38 Revised August 2024 ACKNOWLEDGEMENT RECEIPT NOTICE OF PRIVACY PRACTICES Stephouse Recovery, Inc. 9679 Ellis Ave. Fountain Valley, CA 92708 I acknowledge that I have received a copy of the Notice of Privacy Practices Stephouse Recovery, Inc. The Notice of Privacy Practices describes the types of uses and disclosure of my protected health information that might occur in receipt of sober living services, payment for services, or in the performance of the office operations. The Notice of Privacy Practices also describes my rights and the responsibilities and Stephouse Recovery, Inc. with respect to my protected health information. Stephouse Recovery reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Notice of Privacy Practices. I may also obtain a revised Notice of Privacy Practices by requesting that one be mailed to me. MY SIGNATURE BELOW ACKNOWLEDGES I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES. ALL OF MY QUESTIONS HAVE BEEN ANSWERED AND I UNDERSTAND THAT I MAY MAKE INQUIRY TO THIS ACKNOWLEDGEMENT AT ANY TIME. ______________________________________ __________________ CLIENT NAME (PRINTED) DATE ________________________________________________________ CLIENT SIGNATURE OFFICE USE ONLY: RECORD OF ACKNOWLEDGEMENT NOT OBTAINED ACKNOWLEDGEMENT WAS NOT OBTAINED FOR THE FOLLOWING REASON(S): ☐ Needed more time to review Notice of Privacy Practices. ☐ Wanted to consult with another person before signing. ☐ Unable to sign. ☐ Reason not given ☐ Other (please explain) __________________________________________ ___________________________________ CLIENT NAME (PRINTED) _________________________________________ ________________ STEPHOUSE RECOVERY STAFF (PRINTED) DATE __________________________________________ STAFF SIGNATURE 57-80- 39 Revised August 2024 EMPLOYMENT TRACKING FORM Client Name: Date: Please indicate your current employment/volunteer/student status: ◻ Employed Full-Time ◻ Employed Part-Time ◻ Attending school ◻ Volunteering ◻ I am not currently employed, volunteering, or enrolled in school at the time of intake to Stephouse Recovery. I will notify the Stephouse staff when this status has changed. I understand that staff will regularly follow up on my progress to obtain employment, volunteer, or enroll in school. If employed part-time, please indicate the approximate number of hours you are working each week. Name, Address & Phone number of Employer: If volunteering, please indicate the approximate number of hours you are volunteering each week. Name, Address & Phone number of the Organization you volunteered for: Name of school you are attending: Are you attending online? Yes ◻ No ◻ Client Signature: _________________________________ Date: _________________ 58-81- EXHIBIT H INTRODUCTORY LETTER To our Neighbors, We would like to take a moment to introduce ourselves to you and share with you our presence in the neighborhood. StepHouse Recovery is a Sober Living residence located at 1601 Baker St. Our mission is to provide a safe and sober environment for individuals transitioning from a treatment program back to mainstream living. Each resident participates in a structured recovery program provided by the Orange County Health Care Agency. StepHouse operates with the oversight of Orange County Health Care Agency and the Orange County Sheriff’s Department, as well as permission from the City of Costa Mesa. A well trained house manager provides round-the-clock supervision for the residents. Should you ever have any disturbance or issue resulting from our home please let us know. Our goal is to be a good neighbor, and we will address any concerns as soon as possible. Below is contact information for Stephouse staff and Orange County Health Care agency staff. Stephouse Recovery George Vilagut info@stephouserecovery.com (888) 923-7623 Orange County Healthcare Agency Monica Curran MCurran@ochca.com (714) 834-2488 or Monica Cabral MoCabral@ochca.com (714) 834-2027 Sincerely, George Vilagut Executive Director Stephouse Recovery, Inc. 59-82- closet closet closet li n e n closet cl o s e t HVAC closet 11’ x 5’ bathroom bathroom 11’ x 5’ window sliding door window wi n d o w window wi n d o w wi n d o w window window window wi n d o w front door recreation room 24’ x 16’ kitchen 13’ x 11’ dining room 21’ x 11’ living room 13’ x 8’ 12’ x 14’ 2 people bedroom 12’ x 14’ 2 people bedroom 15.5’ x 10’ 1 person bedroom 11’ x 11’ 1 person bedroom 9’ x 11’ House manager bedroom hallway 17’ x 3.5’ 2 Car Garage (resident parking) Parking for 3 vehicles on driveway Residence total square footage is 2200 sq ft EXHIBIT F -83- EXHIBIT G -84- -85- -86- Page 1 of 43 STEPHOUSE RECOVERY POLICIES AND PROCEDURES OCHCA RECOVERY RESIDENCE SERVICES ATTACHMENT 6 -87- Page 2 of 43 TABLE OF CONTENTS NONDISCRIMINATION 4 PHILOSOPHY STATEMENT 4 FISCAL PRACTICES 4 SHARING INFORMATION WITH STAFF AND CLIENTS 5 Procedure for Notifying Program Staff and Clients of P&P Updates 5 GRIEVANCE AND COMPLAINT PROCESS & POLICY 5 SPECIAL INCIDENT REPORTING AND NOTIFICATION OF DEATH 7 EMERGENCY RESPONSE PLAN 8 FACILITY REQUIREMENTS 8 MANDATORY POSTINGS FOR HOUSES 9 HOUSE LOG POLICY 9 COVID-19 CORONAVIRUS POLICY 9 STAFF REQUIREMENTS FOR EMPLOYMENT 11 EMPLOYEE FILE POLICY 12 OCHCA COMPLIANCE PROGRAM ACKNOWLEDGEMENT 13 LITERATURE, ADVERTISEMENTS, AND SOCIAL MEDIA COMPLIANCE 13 NO PROSELYTIZING POLICY 13 CODE OF CONDUCT 14 DUTIES of DIRECTOR and HEAD of ADMINISTRATIVE STAFF 15 EMPLOYMENT EQUAL OPPORTUNITY COMPLIANCE 15 ANTI-HARASSMENT POLICY & COMPLAINT PROCEDURE 16 STAFF DRUG TEST POLICY 18 STAFF DISCHARGE PROCEDURE 18 DRUG-FREE WORKPLACE POLICY 18 INSPECTIONS AND AUDITS 19 REPORTING AND BILLING POLICY AND PROCEDURE 20 COMPLIANCE 20 GENERAL AND SPECIALIZED PROVIDER COMPLIANCE TRAINING 20 MEDICAL BILLING, CODING, AND DOCUMENTATION COMPLIANCE STANDARDS 21 INSURANCE STANDARDS 21 RECORDS POLICY & PROCEDURES 23 RECORDS MANAGEMENT AND MAINTENANCE 23 HIPAA PRIVACY AND SECURITY/NOTICE OF PRIVACY PRACTICES 25 BREACH POLICY 26 INTAKE POLICY AND PROCEDURE 27 OUTPATIENT PARTICIPATION POLICY 28 OUTPATIENT TREATMENT PARTICIPATION COLLECTION 28 TRACKING PROCEDURE 28 CLIENT RELAPSE POLICY 29 DISCHARGE PROCEDURES FOR STAFF 29 RECORDS RETENTION POLICY 30 DENIED ADMISSION POLICY 31 ALTERNATIVE REFERRAL POLICY 31 CLIENT ELIGIBILITY 31 -88- Page 3 of 43 CLIENT REQUIREMENTS 31 STEPHOUSE RECOVERY’S POLICIES AND PROCEDURES The following policies and procedures are shared with the client at intake AUTHORITY POLICY 32 CLEANING POLICY 32 CLIENT CONFIDENTIALITY POLICY 32 CLIENT SIGN-IN/OUT POLICY – CLIENT SCHEDULES 33 OUTPATIENT PARTICIPATION POLICY 33 CURFEW/OVERNIGHT POLICY 33 DISCHARGE/TERMINATION POLICY 34 DISCRETION POLICY 35 DRUG/ALCOHOL POLICY 35 SUPPORT STAFF 35 EMPLOYMENT/SCHOOL/VOLUNTEERING POLICY 35 GOOD NEIGHBOR POLICY 36 HOUSE RULES POLICY 37 MAIL AND PACKAGE DELIVERY POLICY 38 MEALS/FOOD POLICY 38 MOTOR VEHICLE (INCL. MOTORCYCLE) POLICY 39 NONDISCRIMINATION POLICY 39 OPIOID OVERDOSE EMERGENCY TREATMENT POLICY 39 PROPERTY DAMAGE POLICY 39 DRUG & ALCOHOL SCREENING POLICY 40 SMOKING POLICY 40 TRANSGENDER & GENDER IDENTITY POLICY 40 GENDER-ORIENTED FACILITY POLICY 41 TRANSPORTATION POLICY 41 VISITATION POLICY 41 NO RESPONSIBILITY CLAUSE 41 ADDENDUM A 42 -89- Page 4 of 43 NONDISCRIMINATION It is the policy of Stephouse Recovery not to discriminate in employment practices and provision of benefits and services on the basis of race, color, national origin, religion, sex, or mental or physical disabilities, pursuant to Title VI of the Civil Rights Act of 1964 (Section 2000d, Title 42, United States Code), the Rehabilitation Act of 1973 (Section 794, Title 29, United States Code); the Americans with Disabilities Act of 1990 (Section 12132, Title 42, United States Code); Section 11135 of the California Government Code; and Chapter 6 (commencing with Section 10800), Division 4, Title 9 of the California Code of Regulations. MISSION STATEMENT Our mission at Stephouse Recovery is to provide comprehensive, integrated mental health, substance abuse, and behavioral modification services that promote the health and well-being of our clients to improve their quality of life. PHILOSOPHY STATEMENT Our goal is to individualize behavior plans and recovery-based treatment plans to assist our clients in achieving their desired goals in sobriety and everyday life. Here at Stephouse Recovery, we strive to create a positive environment that encourages optimism and instills a comfortable feeling where clients can allow themselves a platform to open up to alternative health choices in their recovery. Our methods are proven effective because we use evidence-based practices. We have a state-of-the- art structured environment that is fully staffed with qualified personnel who offer guidance, consistency, and support. We encourage our clients to hold themselves to a higher standard and take accountability for their actions while promoting self-confidence and self-reflection on their journey towards sobriety and a productive way of life. Our hope is to teach each client how to break their substance abuse cycle so they can make a conscious choice to walk a different path and lead a more productive, healthy lifestyle. FISCAL PRACTICES Stephouse Recovery implements standard cash basis accounting and bookkeeping practices. Expenses and revenue are recorded on a weekly basis by a contracted bookkeeper. Stephouse Recovery’s CPA office typically handles journal entries. All bookkeeping is reviewed quarterly by the CPA office. Receipts and/or invoices are required to be attached to all expenses. Only Stephouse Recovery Owner has the authority to sign checks and make bank deposits. The bookkeeper reconciles accounts at the first of every month for the previous month’s activity. Bank statements are reviewed monthly by Stephouse Owner. The organization’s quarterly financial statements are prepared in accordance with Generally Accepted Accounting Principles (GAAP) by the Stephouse Recovery CPA office. The bookkeeper handles employee payroll bi-weekly and ensures that all payroll taxes and forms are paid and filed in a timely manner. The CPA and Stephouse House Recovery Owner oversee all other taxes and related forms for the organization. Timesheets are to be signed and turned in to Stephouse Recovery Owner for review on the Monday preceding the scheduled payday. The bookkeeper receives the approved timesheets from the Stephouse Recovery Owner or his assigned delegate only and then makes any changes to the payroll system. Stephouse Recovery Compliance Officer oversees the completion of the Orange County Annual Cost Report for reporting on the use of county funds. Financial records are stored in the QuickBooks Online system and the organization’s Google Shared Drive Banking folder. Records are kept indefinitely. Petty Cash is not utilized in the RRS Program. -90- Page 5 of 43 SHARING INFORMATION WITH STAFF AND CLIENTS Stephouse Recovery's policy is to keep all staff and residents informed and updated on all personnel policies. Staff are emailed when policies and procedures are revised or added to. At house meetings, residents are notified and provided copies of policy and procedure changes. Procedure for Notifying Program Staff and Clients of P&P Updates Policies and Procedures are reviewed annually for necessary updates and revisions. Program staff and clients will be informed of any updates during staff meetings and house meetings immediately following the updates. Copies of the updates will be distributed with a memo outlining the changes that have been made. Staff and clients will be required to sign a group acknowledgement form indicating they received the memo and a copy of the new policy/procedure. GRIEVANCE AND COMPLAINT PROCESS & POLICY Stephouse Recovery's policy is not to discriminate based on race, color, national origin, sex, age, or disability. Stephouse Recovery has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. Section 18116) and its implementing regulations at 45 C.F.R. pt. 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination based on race, color, national origin, sex, age, or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined in the Office of Compliance, who has been designated to coordinate the efforts of HCA's compliance with Section 1557. Any person who believes they have or someone else has been subjected to discrimination on the basis of race, color, national origin, sex, age, or disability may file a grievance under this procedure. It is against the law for Stephouse Recovery to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. This policy applies to individuals (i.e., clients/patients) participating in healthcare programs or activities within Stephouse Recovery. All Stephouse Recovery employees who receive or respond to grievance calls must incorporate the procedures indicated within this policy into current Service Area grievance response procedures. Grievances must be submitted to the Office of Compliance Civil Rights Coordinator within sixty (GO) days of the date the person filing the grievance becomes aware of the alleged discriminatory action. A complaint must be in writing and contain (1) the name and address of the person filing the complaint, (2) the problem or action alleged to be discriminatory, and (3) the remedy or relief sought. 1. Office of Compliance CIVIL RIGHTS COORDINATOR Grievance Procedures a. The Office of Compliance Civil Rights Coordinator (or her/his designee) tracks all complaints/grievances related to race, color, national origin, sex, age, or disability on an internal tracking log. b. The Office of Compliance Civil Rights Coordinator (or her/his designee) notifies the respective Service Area Grievance Representative of Section 1557 complaints and conducts investigations of complaints. This investigation may be informal, but it will be thorough, allowing all interested people to submit evidence relevant to the complaint. c. The Office of Compliance Civil Rights Coordinator tracks the response time of 1557 complaints to ensure that response letters from the respective Service Areas are mailed out within thirty (30) days after its filing, along with a notice to the complainant of the complainant's right to pursue further administrative or legal remedies. d. The Office of Compliance Civil Rights Coordinator maintains HCA files and records relating to Section 1557 grievances. To the extent possible, and per applicable law, the Office of -91- Page 6 of 43 Compliance Civil Rights Coordinator takes appropriate steps to preserve the confidentiality of files and records relating to grievances and shares it only with those who need to know. Appeal Process 2. The person filing the grievance may appeal the decision of the Office of Compliance Civil Rights Coordinator (or her/his designee) by writing to the Civil Rights Appellate Board within fifteen (15) days of receiving the Office of Compliance Civil Rights Coordinator's (or her/his designee's) decision. The Civil Rights Appellate Board issues a written decision in response to the appeal no later than thirty (30) days after its filing. a. The Civil Rights Appellate Board investigates the appeal complaint. b. The Civil Rights Appellate Board issues a written decision on the grievance appeal to the Appellant within thirty (30) days of receipt of the appeal. c. The Office of Compliance Civil Rights Coordinator maintains copies of all correspondence. SERVICE AREA. Grievance Procedures 1. If the grievance is related to race, color, national origin, sex, age, or disability, the Service Area must immediately notify the Office of Compliance Civil Rights Coordinator that the grievance is a 1557 issue. 2. The Service Area follows the grievance process per Service Area procedures. 3. The Service Area responds to the complainant: a. No later than thirty (30) days after the grievance was filed and includes a notice to the complainant advising the complainant's right to pursue further administrative or legal remedies (paragraph C(l)). b. Per Service Area procedures; and c. With the content of the 1557 Formal Response Addendum (Attachment 1) in the response letter. 4. The Service Area provides copies of all correspondence to the Office of Compliance Civil Rights Coordinator. The following explains your right to file a written grievance or complaint to Stephouse Recovery. You can file a complaint if you believe a serious issue has arisen. If you cannot submit a written complaint, you may instead explain your complaint in person or over the telephone, or we can help you to make a written complaint. Grievance Rights If you are already a participant of Stephouse Recovery or are asking for our help, you have a right to file a written grievance if you are unhappy with our services. For example, you might want to file a grievance if you believe that (1) we did not provide you with effective services, (2) we wrongly denied you help, or (3) we violated our legal obligations. If requested, we can give you more detailed information about what the law requires of our programs. How to File a Grievance 1. Please mail a letter describing your grievance to the Stephouse Recovery Executive Director. Sign and date the letter and provide your return address. If you cannot give us a written grievance, you may give us your grievance verbally (e.g., by telephone or in person) or ask us to help you write it. Note: You must submit your grievance within 30 days of the incident. a. Written grievances should be mailed to the attention of the Executive Director of Stephouse Recovery at 9769 ELLIS AVENUE, FOUNTAIN VALLEY, CA 92708. b. If you provide a return address, you will receive a written response within 15 days. 2. If you are unhappy with the Executive Director's decision/response, please mail your written appeal to our Board of Directors asking that the Board review the decision. Sign and date the letter and provide your return address. If you cannot write your grievance, call our business office and request assistance from -92- Page 7 of 43 one of our staff. Note: You must make your appeal within 30 days of receiving the Executive Director's decision. If the County funds your services, you may contact the Orange County Health Care Agency Behavioral Health Services to file a grievance or appeal. 3. Written appeals should be mailed to the attention of the Chair of the Board at 9769 Ellis Avenue, Fountain Valley, CA 92708. 4. If you need more information about your rights under this policy and/or need to make a grievance or appeal verbally, please call our business office at 888-923-7623. SPECIAL INCIDENT REPORTING AND NOTIFICATION OF DEATH A completed Special Incidence Form (SIR), using the OCHCA SIR template will be within 24 hours of a qualifying incident. Qualifying incidents include: • Death of a current client, employee, or visitor that occurs on site or offsite during program related activity. • Death of a former client that occurs within a year of leaving treatment. • Injuries (incl. self-injury) requiring professional medical care. • Automobile accidents • Acts of negligence or serious breach of staff code of conduct • Loss or damage to any COUNTY property in program’s possession • Theft or vandalism which includes staff or clients. • Violence leading to injury, trauma, or police involvement. • Overdose of current client. Include use of any naloxone. • Any sexual contact between client and staff or non-consensual between clients • Tarasoff threats • Any incident of a serious nature that exposes the county to liability. These incidents shall be submitted to program monitor only. • Injury, self- injury, suicide attempt not requiring professional medical care. • Inappropriate staff behavior toward clients or other staff • Any hate crime, or any discrimination or harassment based on race, sexual orientation, gender, or disability. • Significant property damage – fire, flood, earthquake • Physical altercation between residents – no medical care or police involvement • Discovery of any alcohol or narcotics at the facility • Drug or alcohol use occurring at the facility. • Routine illness requiring offsite medical care. • Positive drug test (excluding at admission) Additional details that emerge, follow-up and background info shall be provided in addendum within 48 hours of incident. Email Notification to HPS (SIR form not required): Notice of any serious contagious medical condition that requires containment, including (but not limited to): COVID 19, Measles, Mumps and Rubella, Tuberculosis, Chicken Pox, Pertussis (whooping cough), Hepatitis A, Meningococcal Meningitis – include housing plan for affected clients. Upon becoming aware of the death of any person served pursuant to the OCHCA Resident Recovery Service Contract, Stephouse Recovery shall immediately notify OCHCA Program Staff. -93- Page 8 of 43 • All Notifications of death shall contain the name of the deceased, the date and time of death, the nature and circumstances of the death, and the name(s) of Stephouse Recovery Staff with knowledge of the incident. • Stephouse Recovery shall notify OCHCA Program Staff by telephone immediately upon becoming aware of the death due to non-terminal illness of any person served pursuant OCHCA Resident Recovery Service Contract. Notice will only be given during normal business hours. • All death reports will be verified by the coroner’s office. EMERGENCY RESPONSE PLAN Call 911 in the event of: 1. Fire 2. Violence or a threat of violence 3. Suspicious persons hanging around premises 4. Burglary 5. A life-threatening medical situation 6. Chest pain 7. Shortness of breath 8. Suicide attempt 9. Unconscious individual 10. Injury in which there is a broken bone or bleeding that cannot be stopped 11. Serious fall 12. Unable to wake someone 13. Ingestion of toxic chemicals or substances 14. Suspected overdose of a substance or alcohol 15. Individual out of control 16. Individual hallucinating 17. Individual having an extreme allergic reaction 18. Extreme paranoid behavior When overdose is suspected - administer Naloxone to the individual in crisis and dial 911. After a resident calls 911, they should call the house manager/management and inform them of the situation. Make sure you move to a safe place to wait for the arrival of emergency assistance. DO NOT try to move an injured person, give First Aid or CPR unless you are qualified. Upon intake, the House Manager will ensure that all residents are aware of the emergency exit routes and location of fire extinguishers for the residence. Phone numbers for the House Manager, Stephouse Recovery Management, and OC HCA Program Officers shall be kept current on the bulletin board in the common area of the residence. FACILITY REQUIREMENTS THE RECOVERY RESIDENCE FACILITY SHALL BE CLEAN, SAFE, SANITARY, AND IN GOOD REPAIR AT ALL TIMES AND SHALL INCLUDE: a. An alcohol and drug free living environment b. Safe sleeping quarters, a separate bed for each client, closet and dresser space, clean linen in good repair, including lightweight, warm blankets; top and bottom sheets; pillowcases; -94- Page 9 of 43 mattress pads; bath towels and wash cloths. c. Bedrooms shall not be overcrowded, allowing 70 square feet for the first two people and 50 square feet for each additional person in bedrooms, unless given prior written approval by the County of Orange d. Basic living facilities including but not limited to: adequate bathing, hand washing and toilet facilities, lounge area, and dining area with adequate seating. e. Laundry facilities and laundry supplies at no cost to the Client. f. Toiletry articles appropriate to the health and grooming needs of the Client. MANDATORY POSTINGS FOR HOUSES The following documents are required to be posted at all County contracted Recovery Residence Services homes: • Current Copy of the Sheriff Certification- Expires _j _j • House Rules, Visitation, and Non-Smoking rules if they are not noted in the House Rules (including a curfew and visitation hours) • Current Copy of the Sheriff Certification Guidelines • House manager information/ Hours that individual staff members will be on site • Prohibition against Alcohol and Non-Prescription Drugs • Sexual Harassment of Client or Staff is Prohibited Notice • Grievance Procedure • Good Neighbor Policy • Client Sign-In/Sign-Out Log • Evacuation plan • List of resources within the community that includes medical, dental, mental health, public health, and social services. • Where to apply to determine eligibility for state, federal, or county entitlement programs. • Information on self-help meetings. AA, NA, and non-12-step meetings. HOUSE LOG POLICY Stephouse Recovery shall maintain a house log on each shift supervised by a designated staff member. The log shall be used to document staff and shift changes at the Recovery Residence and client and staff related incidents (e.g., altercations, curfew infractions, policy breaches by clients and staff, etc.). The log provides a space to document the date, time of the incident, and the printed name, signature, and title of the staff member completing the entry. COVID-19 CORONAVIRUS POLICY The COVID-19 situation is changing rapidly, and we recommend that staff and clients monitor the information from the CDC and CA Governor's State of Emergency for updates. In response to the State Public Health Officer Order dated August 9, 2021, Stephouse Recovery is providing this plan to address vaccine status verification, masking requirements, and COVID-19 testing requirements. If you believe you may have been exposed to COVID-19 or have symptoms that may indicate exposure, please contact your supervisor as soon as possible and before coming to work. Symptoms that may indicate exposure to COVID-19 include any one of the following: • Cough • Fever • Loss of smell • Muscle aches • Runny nose -95- Page 10 of 43 • Shortness of breath • Sore throat Employee and Client policies and protocols 1. All Stephouse Recovery staff and clients must self-monitor for symptoms concerning COVID-19 infection. If a client displays symptoms or has a high fever, staff will contact the HCA COVID-19 Disease Control for Shelters Help Line to help the client get connected with testing and quarantining at a hotel if necessary. 2. Stephouse Recovery will contact HCA COVID-19 Disease Control for Shelters Help Line: (714) 567- 6246 if we have a question or need assistance related to a suspected or confirmed COVID-19 case. 3. Stephouse Recovery follows the most current CDC recommendations for quarantining following exposure to COVID-19. 4. Asymptomatic healthcare workers are to follow protocols in accordance with current state regulations before returning to work after potential COVID-19 exposure. 5. Staff under quarantine due to COVID-19, who are not required to be onsite, may work remotely with approval from their direct supervisor. 6. You might be asked to practice self-quarantine if you have recently returned from traveling to a part of the country or the world where COVID-19 is spreading rapidly or if you have knowingly been exposed to an infected person. At Stephouse Recovery, self-quarantine involves: • Using standard hygiene and washing hands frequently • Not sharing things like towels and utensils • Staying in your room and asking for assistance from staff • Staying at least 6 feet away from other people in your household • Always wearing an FDA-cleared surgical mask Once a quarantine period has ended, and the person no longer has symptoms, staff must produce a negative COVID-19 test before returning to work. Clients must provide a negative COVID-19 test before returning to a normal house routine. Respirator and Masking Requirements Stephouse Recovery monitors and follows current California Department of Public Health (CDPH) COVID- 19 masking requirements. Stephouse Recovery reserves the right, at our discretion, to go above and beyond CDPH masking requirements in our facilities. Stephouse Recovery will regularly update staff on facility masking requirements via written memorandum. When required, staff may only wear FDA-cleared surgical masks provided by Stephouse Recovery. Cloth and other non-FDA-cleared face coverings are not allowed. When required, workers, regardless of vaccination status, must wear masks in indoor settings and anywhere they are working with another person. Stephouse Recovery does not use respirators in our facilities. Testing Requirements Stephouse Recovery abides by the most current CDPH COVID-19 testing requirements. Asymptomatic unvaccinated, or incompletely vaccinated workers may be tested at least once weekly with either PCR or antigen testing. Unvaccinated or incompletely vaccinated workers must also observe all other infection control requirements, including masking, and are not exempted from testing requirements even if they have a medical contraindication to vaccination as they are still potentially able to spread the illness. Persons with a previous history of COVID-19 from which the individual recovered more than 90 days earlier or a previous positive antibody test for COVID-19 do not waive requirements for testing. Diagnostic screening testing of asymptomatic fully vaccinated workers is not currently required. Stephouse Recovery is required to track test results, conduct workplace contact tracing, and must report results to local public health departments. Intake Screening: -96- Page 11 of 43 During intake, all clients at Stephouse Recovery have their temperature taken (must be less than 100.4 degrees to be admitted) and are screened for any presenting illness with the following questions: • Do you have any aches or chills? • Do you have a headache? • Do you have a cough? • Are you experiencing shortness of breath? • Do you have any other symptoms of illness? Social Distancing, Hygiene, Cleanliness At Stephouse Recovery, we have implemented and encouraged social distancing at all our facilities by promoting the following: • Clients are to stay at least 6 feet (2 meters) from other people • Stay home whenever possible • Do not gather in groups inside or outside of the home • When out of the home, stay out of crowded places and avoid mass gatherings • COVID-19 safety is discussed in house meetings at the homes, and there are postings at the front door of each home. Additionally, Stephouse Recovery clients are encouraged to: • Wash hands thoroughly • Clean and disinfect surfaces frequently • Use hand sanitizer • Cover mouth when coughing • Wear masks or facial cover STAFF REQUIREMENTS FOR EMPLOYMENT All candidates for full or part-time employment, volunteers, and interns, prior to starting services, shall meet the following requirements: 1. No person shall have been convicted of a sex offense for which the person must register as a sex offender under PC section 290. 2. No person shall have been convicted of arson violating PC sections 451, 451.1, 451.5, 452,45231,453,454, or 455. 3. No person shall have been convicted of any violent felony as defined in PC section 667.5, which involves doing bodily harm to another person for which the staff member was convicted within five (5) years prior to employment. 4. No person shall be on parole or probation. 5. No person shall participate in the criminal activities of a criminal street gang and/or prison gang. 6. No person shall have a prior employment history of improper conduct, including but not limited to forging or falsifying documents or drug tests, sexual assault or sexual harassment, or inappropriate behavior with staff or residents at another treatment facility. 7. The Compliance Officer will be notified of any changes in the personnel holding staff positions. Exceptions to staffing requirements set forth above may be requested if Stephouse Recovery deems the decision will benefit the program. Requests for exceptions shall be submitted in writing and also may need to be approved in advance by OCHCA. BACKGROUND SCREENING – Stephouse Recovery screens all candidates before their date of hire. Fingerprinting live scans are required for licensed clinical staff. All new staff must also pass a background check, including volunteers and interns. Stephouse Recovery background check includes the following -97- Page 12 of 43 1. A National and County Search for prior infractions, misdemeanors, felony convictions, and pending cases found at the state or county level. 2. A search of the National Sex Offenders registry 3. A Global Watchlist Search to screen for suspected terrorists, money launderers, fraudsters, politically exposed persons (PEPs), adverse media, or sanctions lists maintained by governments and regulatory agencies. 4. A social security number trace. 5. A motor vehicle report. 6. The Orange County Courts database. 7. The Megan’s Law website. 8. The Office of Inspector General’s exclusions list. 9. CA Medi-Cal exclusions list 10. The System for Award Management (Sam.gov) website, the US government exclusions list CONFLICT OF INTEREST- Employees are forbidden from engaging in any other business that competes with Stephouse Recovery. Also, employees are forbidden from obtaining a financial interest in an outside concern that does business with or is a competitor of Stephouse Recovery (except where such ownership consists of securities of a publicly owned corporation regularly traded on the public stock market). Rendering of the directive, managerial, or consulting services to any outside concerns that does business with or is a competitor of Stephouse Recovery (except with the knowledge and written consent of Stephouse Recovery) is also prohibited. If you think that there is a possibility that you may have a conflict, it is your responsibility to notify Stephouse Recovery and obtain approval in writing. TRAINING – All employees, select contractors, interns, and volunteers are required to complete a staff orientation that includes a review of Stephouse Recovery Policies and Procedures and expectations for performance. All staff must complete the following within six months of beginning work with Stephouse Recovery: 1. Orange County Healthcare Agency (OCHCA) Annual Provider Training 2. OCHCA Annual Compliance Training 3. Cultural Competency Training 4. Infectious Disease Recognition 5. Crisis Intervention 6. HIPAA Privacy and Confidentiality 7. Alcohol and Substance Abuse related training 8. CPR & Basic First Aid 9. Recognizing Symptoms Requiring Appropriate Referral EMPLOYEE FILE POLICY Each employee file must contain the following: Application for Employment Drug & Alcohol Testing Consent & Results Resume TB Skin Test Report (conducted annually) Job Description - signed COVID vaccination card Background Check w/signed consent COVID Vaccine Status Certification Copy of Driver’s License Masking & Testing Requirements Attestation Proof of Car Insurance Probationary Period Acknowledgement Copy of Social Security Card Confidentiality Agreement Form I-9 Code of Conduct W-4 HIPAA Agreement Wage & Hour/Meal Break Acknowledgment Anti-Defamation Clause -98- Page 13 of 43 Training Certificates Employee Handbook Acknowledgement Exclusions & County Screening Print Outs OCHCA COMPLIANCE PROGRAM ACKNOWLEDGEMENT The Chief Executive Officer shall acknowledge in writing, on behalf of Stephouse Recovery, that he is aware of and will adhere to the County of Orange Health Care Agency's Compliance Program, Code of Conduct, and related policies and procedures and shall ensure Stephouse Recovery employees, subcontractors, interns, volunteers, and members of Board of Directors or duly authorized agents (if appropriate), relative to the Agreement(s) for the Provision of AB 109 RESIDENTIAL TREATMENT SERVICES and Recovery Residence Services are made aware of and adhere to the County of Orange Health Care Agency's Compliance Program, Code of Conduct, and related policies and procedures. A signed copy of the acknowledgment shall remain on file with Stephouse Recovery compliance documents. LITERATURE, ADVERTISEMENTS, AND SOCIAL MEDIA COMPLIANCE A. Any written information or literature, including educational or promotional materials, distributed by Stephouse Recovery to any person or organization for purposes directly or indirectly related to this Contract must be approved at least thirty (30) days in advance and in writing by ADMINISTRATOR before distribution. For the purposes of this Contract, distribution of written materials shall include, but not be limited to, pamphlets, brochures, flyers, newspaper or magazine ads, and electronic media such as the Internet. B. Any advertisement through radio, television broadcast, or the Internet, for educational or promotional purposes, made by Stephouse Recovery for purposes directly or indirectly related to this Contract must be approved in advance at least thirty (30) days and in writing by ADMINISTRATOR. C. If Stephouse Recovery uses social media (such as Facebook, Twitter, YouTube or other publicly available social media sites) in support of the services described within this Contract, Stephouse Recovery shall develop social media policies and procedures and have them available to ADMINISTRATOR upon reasonable notice. Stephouse Recovery shall inform ADMINISTRATOR of all forms of social media used to either directly or indirectly support the services described within this Contract. Stephouse Recovery shall comply with COUNTY Social Media Use Policy and Procedures as they pertain to any social media 28 of 39 RECOVERY RESIDENCE SERVICES MASTER AGREEMENT – FY 2023-26 MA-042-23011088 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 developed in support of the services described within this Contract. Stephouse Recovery shall also include any required funding statement information on social media when required by ADMINISTRATOR. D. Any information as described in Subparagraphs A. and B. above shall not imply endorsement by COUNTY, unless ADMINISTRATOR consents thereto in writing. E. Stephouse Recovery shall also clearly explain through these materials that there shall be no unlawful use of drugs or alcohol associated with the services provided pursuant to this Contract, as specified in HSC, §11999-11999.3. For additional information, policy, and procedure regarding social media please refer to Addendum A. NO PROSELYTIZING POLICY Stephouse Recovery shall not conduct any proselytizing activities, regardless of funding sources, with respect to any person who has been referred to Stephouse Recovery by the County under the terms of the Agreement. Stephouse Recovery agrees that funds provided by County shall not be used to promote, directly or indirectly, any religion, religious creed or cult, denomination or sectarian institution, or religious belief. -99- Page 14 of 43 CODE OF CONDUCT I acknowledge that I am aware of and will adhere to the Stephouse Recovery Code of Conduct and related policies and procedures, which are as follows: Employees, subcontractors, interns, volunteers, members of the Board of Directors, and duly authorized agents • are prohibited from manufacturing, cultivating, distributing, dispensing, possessing, or using illegal drugs (including marijuana) or other unauthorized or mind-altering or intoxicating substances while on Stephouse Recovery's property (including parking areas and grounds), or while otherwise performing work duties away from Stephouse Recovery's property. This prohibition includes lawfully controlled substances that have been illegally or improperly obtained. This policy does not prohibit the possession and proper use of lawfully prescribed drugs taken in accordance with the prescription. Off-duty possession, use, sale, or purchase of mind- altering substances and off-premises alcohol abuse is also prohibited. Alcohol abuse for the purpose of this off-duty conduct rule includes unruly behavior by an employee, which may tend to harm the reputation of Stephouse Recovery. • are committed to contributing to a work environment that is free of unlawful harassment. • always maintain the respect and dignity of each client. • are prohibited from engaging in abuse. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, punishment, humiliating, harassing, or threatening, resulting in physical harm, pain, or mental anguish. Any verbal, emotional, or physical abuse towards clients, visitors, and/or other staff is strictly prohibited. • always maintain a professional relationship with all clients. This includes avoiding all conflicts of interest, fraternization, and/or any sexual contact with clients. • are strictly prohibited from all forms of unlawful harassment, which includes harassment based on race, religion, color, sex, gender identity, sexual orientation, national origin, ancestry, citizenship status, uniform service member status, marital status, pregnancy, age, protected medical condition, genetic information, disability, or any other category protected by applicable state or federal law. To prohibit sexual harassment includes a broad spectrum of conduct, including harassment based on gender and gender orientation (meaning one's heterosexuality, homosexuality, bisexuality, etc.). • committed to encouraging residents to accept personal responsibility for their behavior. • do not engage in romantic and sexual relationships with other employees or clients. Intimate or physical (especially sexual) relationships between staff or members of the board of directors and clients are strictly prohibited. This provision will remain in force throughout the client’s length of program service and until they have been out of the program for a minimum of six months. • prohibited from engaging in any other business that competes with Stephouse Recovery and will avoid conflicts of interest and interference with the productivity of other employees. • acknowledge that clients cannot be admitted to the program where a familial relationship exists with an employee of the facility. Business transactions between staff and clients (or their families) are not permitted without administrative approval. • forbidden from obtaining a financial interest in an outside concern that does business with or is a competitor of Stephouse Recovery (except where such ownership consists of securities of a publicly owned corporation regularly traded on the public stock market). Rendering of directive, managerial, or consulting services to any outside concern that does business with or is a competitor of Stephouse Recovery (except with the knowledge and written consent of Stephouse Recovery) is also prohibited. If you think that there is a possibility that you may have a conflict, it is your responsibility to notify Stephouse Recovery and obtain approval in writing. -100- Page 15 of 43 • understanding that records and files related to Stephouse Recovery business and clients are the property of Stephouse Recovery and are considered confidential. Confidential information includes all letters or any other information concerning transactions with customers, customer lists, payroll or personnel records of past or present employees, financial records, all records pertaining to purchases from vendors or suppliers, correspondence and agreements with manufacturers or distributors, and documents concerning operating procedures. All telephone calls, letters, or other requests for information about current or former employees should be immediately directed to management. Any information, recorded or not, relating to a client of any Stephouse facility is confidential and protected by the Code of Federal Regulations Title 42, Chapter 1, Part 2; the State of California Welfare & Institution Code, Sections 5326-5330, and other provisions. These regulations prohibit the disclosure of information either while employed or afterward. DUTIES of DIRECTOR and HEAD of ADMINISTRATIVE STAFF Duties of Director- The director, also known as the manager of recovery residence, is responsible for supervising all clients and all staff employed by or volunteering for the facility. They are responsible for the overall management, safety, compliance, and performance of the organization and each of the residences. Duties of House Manager- Each recovery residence shall have a designated house manager or person of some authority who resides at the facility. The house manager shall 1. Generally, monitor residents daily 2. Observe, document, and report resident behavior/progress consistently and continuously. 3. Maintains resident privacy and confidentiality in compliance with HIPAA and other state and federal regulations. 4. Maintains a clean, healthy, and safe environment. 5. Ensures and monitors that each resident has a chore that is completed daily. 6. Report any need for facility maintenance or repairs that may be necessary to operate the home safely to management. 7. Monitor and report on resident curfews: 11:00 PM (with job and sponsor)/10:00 PM (without a job or sponsor) Sun-Thurs; 12:00 (everyone) Fri & Sat. 8. Communicate with the Director when issues are encountered, e.g., relapses, emergencies, behavioral incidents, family issues, etc. 9. House Managers may not engage in dual relationships with residents. Dual relationships include but are not limited to sexual relations or other sexual acts, going into business together, or employment. Stephouse Recovery shall post the telephone number of designated on-call staff immediately upon the absence of Stephouse Recovery’s house manager and/or Director at the facility. EMPLOYMENT EQUAL OPPORTUNITY COMPLIANCE Stephouse Recovery is committed to equal employment opportunity and employs all qualified persons without regard to race, religion, color, national origin, ancestry, citizenship status, uniform service member/veteran status, physical disability, mental disability, medical condition, pregnancy, genetic information, marital status, sexual orientation, gender, gender identity, gender expression, age, or any other classification protected by federal, state, and local laws. Harassment of any kind will not be tolerated. Stephouse Recovery shall also not discriminate against employees or applicants for employment in the areas of employment, promotion, demotion, or transfer; recruitment or recruitment advertising, layoff, or termination; compensation, benefits, leaves of absence, selection for training, including apprenticeship, and other terms and conditions of employment. Stephouse Recovery shall display notices from The County of Orange and the United States Equal Employment Opportunity Commission setting forth the provisions of the Equal Opportunity clause. -101- Page 16 of 43 All solicitations or advertisements for employees placed by or on behalf of Stephouse Recovery shall state that all qualified applicants will receive consideration for employment without regard to race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran status. ANTI-HARASSMENT POLICY & COMPLAINT PROCEDURE Stephouse Recovery strives to create and maintain a work environment where people are treated with dignity, decency, and respect. The environment of the company should be characterized by mutual trust and the absence of intimidation, oppression, and exploitation. Stephouse Recovery will not tolerate unlawful discrimination or harassment of any kind. Through enforcement of this policy and by education of employees, Stephouse Recovery will seek to prevent, correct, and discipline behavior that violates this policy. All employees, regardless of their positions, are covered by and are expected to comply with this policy and to take appropriate measures to ensure that prohibited conduct does not occur. Appropriate disciplinary action will be taken against any employee who violates this policy. Based on the seriousness of the offense, disciplinary action may include verbal or written reprimand, suspension, or termination of employment. Managers and supervisors who knowingly allow or tolerate discrimination, harassment, or retaliation, including the failure to immediately report such misconduct to management, violate this policy and are subject to discipline. Prohibited Conduct Under This Policy Stephouse Recovery, in compliance with all applicable federal, state, and local anti-discrimination and harassment laws and regulations, enforces this policy in accordance with the following definitions and guidelines: Discrimination It is a violation of Stephouse’s policy to discriminate in the provision of employment opportunities, benefits, or privileges; to create discriminatory work conditions; or to use discriminatory evaluative standards in employment if the basis of that discriminatory treatment is, in whole or in part, the person's race (including hairstyle/texture), color, national origin, age, religion, disability status, sex, sexual orientation, gender identity or expression, genetic information or marital status. Discrimination of this kind may also be strictly prohibited by various federal, state, and local laws, including Title VII of the Civil Rights Act of 1964, the Age Discrimination Act of 1967, and the Americans with Disabilities Act of 1990. This policy is intended to comply with the prohibitions stated in these anti- discrimination laws. Discrimination in violation of this policy will be subject to disciplinary measures up to and including termination. Harassment Stephouse Recovery prohibits harassment of any kind, including sexual harassment, and will take appropriate and immediate action in response to complaints or knowledge of violations of this policy. For purposes of this policy, harassment is any verbal or physical conduct designed to threaten, intimidate, or coerce an employee, co-worker, or any person working for or on behalf of Stephouse Recovery. The following examples of harassment are intended to be guidelines and are not exclusive when determining whether there has been a violation of this policy: • Verbal harassment includes comments that are offensive or unwelcome regarding a person's national origin, race, color, religion, age, sex, sexual orientation, pregnancy, appearance, disability, gender identity or expression, marital status, or another protected status, including epithets, slurs, and negative stereotyping. • Nonverbal harassment includes distribution, display, or discussion of any written or graphic -102- Page 17 of 43 material that ridicules, denigrates, insults, belittles, or shows hostility, aversion, or disrespect toward an individual or group because of national origin, race, color, religion, age, gender, sexual orientation, pregnancy, appearance, disability, sexual identity, marital status or another protected status. Sexual harassment Sexual harassment is a form of unlawful employment discrimination under Title VII of the Civil Rights Act of 1964 and is prohibited under Stephouse's anti-harassment policy. According to the Equal Employment Opportunity Commission (EEOC), sexual harassment is defined as "unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature ... when ... submission to or rejection of such conduct is used as the basis for employment decisions ... or such conduct has the purpose or effect of creating an intimidating, hostile or offensive working environment." Sexual harassment occurs when unsolicited and unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature: • Is made explicitly or implicitly a term or condition of employment. • Is used as a basis for an employment decision. • Unreasonably interferes with an employee's work performance or creates an intimidating, hostile, or otherwise offensive environment. Sexual harassment may take different forms. The following examples of sexual harassment are intended to be guidelines and are not exclusive when determining whether there has been a violation of this policy: • Verbal sexual harassment includes innuendoes, suggestive comments, jokes of a sexual nature, sexual propositions, lewd remarks, and threats; requests for any type of sexual favor (this includes repeated, unwelcome requests for dates); and verbal abuse or "kidding" that is oriented toward a prohibitive form of harassment, including that which is sexual in nature and unwelcome. • Nonverbal sexual harassment includes the distribution, display, or discussion of any written or graphic material, including calendars, posters, and cartoons that are sexually suggestive or show hostility toward an individual or group because of sex; sugges tive or insulting sounds; leering; staring; whistling; obscene gestures; content in letters, notes, facsimiles, e -mails, photos, text messages, tweets, and Internet postings; or other forms of communication that are sexual in nature and offensive. • Physical sexual harassment includes unwelcome, unwanted physical contact, including touching, tickling, pinching, patting, brushing up against, hugging, cornering, kissing, fondling, and forced sexual intercourse or assault. Courteous, mutually respectful, pleasant, noncoercive interactions between employees that are appropriate in the workplace and acceptable to and welcomed by both parties are not considered to be harassment, including sexual harassment. Retaliation No hardship, loss, benefit, or penalty may be imposed on an employee in response to: • Filing or responding to a bona fide complaint of discrimination or harassment. • Appearing as a witness in the investigation of a complaint. • Serving as an investigator of a complaint. Lodging a bona fide complaint will not be used against the employee or adversely impact the individual's employment status. However, filing groundless or malicious complaints is an abuse of this policy and will be treated as a violation. Any person who is found to have violated this aspect of the policy will be subject to discipline up to and including termination of employment. Confidentiality All complaints and investigations are treated confidentially to the extent possible, and information is -103- Page 18 of 43 disclosed strictly on a need-to-know basis. The identity of the complainant is usually revealed to the parties involved during the investigation, and the HR director will take adequate steps to ensure that the complainant is protected from retaliation during and after the investigation. All information pertaining to a complaint or investigation under this policy will be maintained in secure files within the HR department. Complaint procedure Stephouse Recovery has established the following procedure for lodging a complaint of harassment, discrimination, or retaliation. The company will treat all aspects of the procedure confidentially to the extent reasonably possible. 1. Complaints should be submitted as soon as possible after an incident has occurred, preferably in writing. The Director may assist the complainant in completing a written statement or, in the event an employee refuses to provide information in writing, the Director will dictate the verbal complaint. 2. Upon receiving a complaint or being advised by a supervisor or manager that a policy violation may occur, the Director will notify senior management and review the complaint with the company's legal counsel. 3. The Director will initiate an investigation to determine whether there is a reasonable basis for believing that the alleged violation of this policy occurred. 4. If necessary, the complainant and the respondent will be separated during the course of the investigation, either through internal transfer or administrative leave. 5. During the investigation, the Director, legal counsel, and other management employees will interview the complainant, the respondent, and any witnesses to determine whether the alleged conduct occurred. 6. Upon conclusion of an investigation, the Director or other person conducting the investigation will submit a written report of his or her findings to the company. If it is determined that a violation of this policy has occurred, the Director will recommend appropriate disciplinary action. The appropriate action will depend on the following factors: a) the severity, frequency, and pervasiveness of the conduct b) prior complaints made by the complainant c) prior complaints made against the respondent; and d) the quality of the evidence (e.g., firsthand knowledge, credible corroboration). If the investigation is inconclusive or if it is determined that there has been no violation of policy but potentially problematic conduct may have occurred, the Director may recommend appropriate preventive action. 7. Senior management will review the investigative report and any statements submitted by the complainant or respondent, discuss the results of the investigation with the Director and other management staff as appropriate, and decide what action, if any, will be taken. 8. Once a final decision is made by senior management, the Director will meet with the complainant and the respondent separately and notify them of the findings of the investigation. If disciplinary action is to be taken, the respondent will be informed of the nature of the discipline and how it will be executed. Alternative legal remedies Nothing in this policy may prevent the complainant or the respondent from pursuing formal legal remedies or resolution through local, state, or federal agencies or the courts. STAFF DRUG TEST POLICY • All staff must be drug tested within the first 30 days of employment. • Staff will be drug tested annually after the initial test. -104- Page 19 of 43 • Staff may be drug tested if under suspicion or requested by management. • All employees who test positive in a confirmed substance test will be subject to discipline up to and including termination. • Employees will be held accountable to the Stephouse Recovery Guidelines on Drug Testing provided to them in Employee Packet. Who is Tested 1. Employees may be required to submit to drug/alcohol screening whenever Stephouse Recovery has a reasonable suspicion that they have violated any of the rules set forth in this policy or in the Stephouse Recovery Code of Conduct. Reasonable suspicion may arise from, among other factors, supervisory observation, co-worker reports or complaints, performance decline, attendance or behavioral changes, results of drug searches or other detection methods. 2. Employees in safety sensitive positions may be tested on a random or periodic basis to the extent permitted by applicable state and federal laws. In addition, various job classifications are categorically subject to random or periodic drug testing to the extent permitted by applicable state and federal laws. Employees involved in a work- related injury or accident may also be subject to testing. STAFF DISCHARGE PROCEDURE When a staff member quits, is terminated, or laid off, Stephouse Recovery will inform Orange County Health Care Agency. Any changes in the personnel holding staff positions must be quickly communicated. DRUG-FREE WORKPLACE POLICY It is the policy of The Stephouse Recovery to comply with local, state, and federal laws, regulations, and standards. Our Health and Safety policy outlines the written procedures to ensure the facility is maintained in a clean, safe, sanitary condition and is an alcohol and drug free environment for staff and clients. Alcohol and Drug Use - Every employee must fully familiarize themselves with the Stephouse Recovery stance on being drug free. Drinking alcoholic beverages on the job or reporting to work while under the influence of alcohol and/or any other drug or narcotic, or at any time on or off the job for the recovery staff, is strictly prohibited. INSPECTIONS AND AUDITS OCHCA, any authorized representative of OCHCA, any authorized representative of the State of California, the Secretary of the United States Department of Health and Human Services, the Comptroller General of the United States, or any other of their authorized representatives, shall to the extent permissible under applicable law have access to any books, documents, and records, including but not limited to, financial statements, general ledgers, relevant accounting systems, medical and Client records, of Stephouse Recovery that are directly pertinent to this Agreement, for the purpose of responding to a beneficiary complaint or conducting an audit, review, evaluation, or examination, or making transcripts during the periods of retention set forth in the Records Management and Maintenance Paragraph of Contract Agreement. Such persons may at all reasonable times inspect or otherwise evaluate the services provided pursuant to the Contract Agreement, and the premises in which they are provided. Stephouse Recovery shall actively participate and cooperate with any person specified in the paragraph above in any evaluation or monitoring of the services provided pursuant to the Contract Agreement and shall provide the above-mentioned persons adequate office space to conduct such evaluation or monitoring. AUDIT RESPONSE Following an audit report, in the event of non-compliance with applicable laws and regulations governing funds provided through the Contract Agreement, OCHCA may -105- Page 20 of 43 terminate the Agreement as provided in the Termination Paragraph or direct Stephouse Recovery to implement appropriate corrective action immediately. A CAP shall be submitted to OCHCA in writing within thirty (30) calendar days after receiving notice from OCHCA. 2. If the audit reveals that money is payable from one Party to the other, that is, reimbursement by Stephouse Recovery to OCHCA, or payment of sums due from OCHCA to Stephouse Recovery, said funds shall be due and payable from one Party to the other within sixty (60) calendar days of receipt of the audit results. If reimbursement is due from Stephouse Recovery to OCHCA, and such reimbursement is not received within said sixty (60) calendar days, OCHCA may, in addition to any other remedies provided by law, reduce any amount owed Stephouse Recovery by an amount not to exceed the reimbursement due OCHCA. A. Stephouse Recovery shall forward to OCHCA a copy of any audit report within fourteen (14) calendar days of receipt. Such audit shall include, but not be limited to, management, financial, programmatic, or any other type of audit of STEP HOUSE RECOVERY's operations, whether the cost of such operation or audit is reimbursed in whole or in part through the Agreement. REPORTING AND BILLING POLICY AND PROCEDURE REPORTS – Stephouse Recovery shall submit a monthly program report to the County of Orange no later than the 10th calendar day following the reporting month. 1. Monthly program reports shall include: a. completion, retention, and abstinence rates b. challenges with implementing the provisions of the County Agreement and a statement that Stephouse Recovery is or is NOT progressing satisfactorily in achieving all the terms of the County Agreement. c. pertinent facts and interim findings d. staff changes e. status of license(s) and certification(s) f. changes in the population served and reasons for any changes COMPLIANCE To ensure adherence to all rules and regulations related to federal and state health care programs, Stephouse Recovery will comply with the Orange County Compliance Program, and Code of Conduct, and make available General Compliance Training and education to Covered Individuals. Stephouse Recovery has designated a Compliance Officer who is responsible for compliance policies and procedures and tracking required training. The Compliance Officer will conduct internal monitoring and auditing and other elements as outlined by the Orange County Compliance Program. Stephouse Recovery will screen all Covered Individuals employed or retained at hire and then monthly thereafter against: • General Services Administrations Excluded Parties List System or • System for Award Management and • Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities and • The California Medi-Cal Suspended and Ineligible Provider List and • Social Security Administration Death Master File Screening is completed to ensure no Covered Individual is designated as an Ineligible Person**. *Covered Individual is defined as all employees, interns, volunteers, contractors, subcontractors, agents, and other persons who provide health care items, and services, or who perform billing or coding functions. **Ineligible Person is defined as any individual or entity who: ● Is currently excluded, suspended, debarred or otherwise ineligible to participate in federal and state health care programs; or ● Has been convicted of a criminal offense related to the provision of health care items or services and -106- Page 21 of 43 has not been reinstated in the federal and state health care programs after a period of exclusion, suspension, debarment, or ineligibility. Covered Individuals are required to disclose to Stephouse Recovery management of any new events that may designate individuals as Ineligible Persons. Stephouse will immediately notify Orange County of any status of change of Covered Individuals. Stephouse will immediately remove Ineligible Persons from involvement with Orange County program operations. GENERAL AND SPECIALIZED PROVIDER COMPLIANCE TRAINING The County of Orange shall make General Compliance Training available to covered individuals: • Stephouse shall use its best effort to encourage completion by all covered individuals. At a minimum Stephouse Recovery shall assign at least one designated representative to complete the General Compliance Training when it is available. • Training will be completed within 30 calendar days of employment or engagement. • Training is to be renewed annually. • Covered individuals attending group training must certify in writing their attendance of compliance training. *The County of Orange shall provide instruction on group training completion. The County of Orange shall make specialized provider training available to covered individuals. • Stephouse shall ensure all covered individuals complete this training. • Training will be completed within 30 days of employment or engagement. • Training is to be renewed annually. Covered individuals attending group training must certify in writing their attendance of compliance training. *The County of Orange shall provide instruction on group training completion. MEDICAL BILLING, CODING, AND DOCUMENTATION COMPLIANCE STANDARDS • Stephouse Recovery shall take reasonable precautions to ensure that the coding of claims, billings and or invoices are prepared and submitted in an accurate and timely manner consistent with federal, state, and county laws and regulations, including the Centers for Medicare and Medicaid Services or their agents. • Stephouse Recovery will not submit false claims. • Stephouse Recovery shall bill for eligible services rendered and fully documented. Must ensure compliance with all billing and documentation requirements. • Stephouse Recovery will promptly investigate and correct any problems or errors in the coding of claims and billing. • Stephouse Recovery has 45 business days to return any overpayment. • Stephouse Recovery will meet HCA MHP Quality Management Program Standards and participate in the quality improvement activities developed in implementing the Quality Management Program. • Stephouse Recovery shall maintain the confidentiality of all records, including billings, and audio and video recordings, in accordance with all applicable federal, state, and county codes and regulations such as 42 SS USC 299dd-2. • All Stephouse Recovery employees shall agree, in writing, with Stephouse Recovery to maintain the confidentiality of all info and records. INSURANCE STANDARDS Stephouse Recovery will retain insurance coverage from a carrier with a minimum rating of A- (Secure A.M. Best's Rating) and VIII (Financial Size Category as determined by the most current edition of the Best's Key -107- Page 22 of 43 Rating Guide/Property–Casualty/United States or ambest.com). Stephouse Recovery is licensed in the state of California. Stephouse Recovery will retain the following types of coverage: • Commercial General Liability • Automobile Liability (Stephouse Recovery will ensure that employees, where applicable, shall retain the same) • Workers' Compensation • Employers' Liability Insurance • Network Security & Privacy Liability • Professional Liability Insurance • Sexual Misconduct Liability Insurance Required Coverage Form: 1. The Commercial General Liability coverage shall be written on ISO form CG 00 01, or a substitute form providing liability coverage at least as broad. 2. The Business Automobile Liability coverage shall be written on ISO form CA 00 01, CA 00 OS, CA 00 12, CA 0020, or a substitute form providing coverage at least as broad. Required Endorsements: The Commercial General Liability policy shall contain the following endorsements, which shall accompany the COI (Certificate of Insurance): • An Additional Insured endorsement using ISO form CG 20 26 04 13 or a form at least as broad naming the County of Orange, its elected and appointed officials, officers, employees, and agents as Additional Insureds, or provide blanket coverage, which will state as required by written agreement. • A primary non-contributing endorsement using ISO form CG 20 01 04 13, or a form at least as broad evidencing that Stephouse Recovery's insurance is primary, and any insurance or self- insurance maintained by the County of Orange shall be excess and non-contributing. **The Commercial General Liability policy shall contain a "severability of interests" clause, also known as a "separation of insureds" clause (standard in the ISO CG 0001 policy). The Network Security and Privacy Liability policy shall contain the following endorsements, which shall accompany the Certificate of Insurance: • An Additional Insured endorsement naming the County of Orange, its elected and appointed officials, officers, agents, and employees as Additional Insureds for its vicarious liability. • A primary and non-contributing endorsement evidencing that Stephouse Recovery insurance is primary, and any insurance or self-insurance maintained by the County of Orange shall be excess and non-contributing. The Workers' Compensation policy shall contain: • A waiver of subrogation endorsement waiving all rights of subrogation against the County of Orange, its elected and appointed officials, officers, agents, and employees, or provide blanket coverage, which will state As Required by Written Agreement **Stephouse Recovery shall notify County in writing within thirty (30) days of any policy cancellation and within ten (10) days for non-payment of premium and provide a copy of the cancellation notice to County. Failure to provide written notice of cancellation shall constitute a breach of Stephouse Recovery’s obligation hereunder and grounds for County to terminate the Agreement. **If Professional Liability and/or Network Security and Privacy Liability are "claims made" policies, Stephouse Recovery shall agree to maintain coverage for two (2) years following the completion of the Agreement. SUBMISSION OF INSURANCE DOCUMENTS 1. The COI and endorsements shall be provided to County as follows: a. Prior to the start of this Agreement b. No later than the expiration date for each policy c. Within thirty (30) calendar days upon receipt of written notice by the County regarding changes to any of the insurance types -108- Page 23 of 43 2. The COI and endorsements shall be provided to the County at the address specified in the Referenced Contract Provision of this Agreement. 3. If Stephouse Recovery fails to submit the COI and endorsements that meet the insurance provisions stipulated in this Agreement by the above specified due dates, The County of Orange shall have sole discretion to impose one or both of the following: a. May withhold or delay any or all payments due Stephouse Recovery until it is submitted to The County of Orange. b. Stephouse Recovery may be assessed a penalty of one hundred dollars ($100) for each late COI or endorsement for each business day c. If Stephouse Recovery is assessed a late penalty, the amount shall be deducted from Stephouse Recovery’s monthly invoice. RECORDS POLICY & PROCEDURES ALL FILES SHALL BE KEPT IN A LOCKED CABINET AND ACCESS SHALL BE LIMITED TO THE CLIENT FILES ON A NEED-TO-KNOW BASIS. Client files may contain: 2. A personal information form that contains: a. Personal data for proper identification b. Length of sobriety and prior recovery experience c. The names of the Client's current outpatient care option (treatment facility or Day Reporting Center) d. Name of referral source to facility 3. The Client's treatment plan recommendations from referral sources and others (Notations about how the facility can assist the Client in implementing their treatment related court orders and or treatment plan recommendations) 4. List of prescribed medication used by the client 5. Waiver of confidentiality, signed at the time of the Client's initial intake into the Recovery Residence Facility 6. Health Care Agency referral form for Recovery Residence Services 7. Copies of all progress reports and all correspondences written by STEPHOUSE RECOVERY staff regarding the Client 8. Dates and results of all drug and alcohol tests and all forms related to such tests (keep the physical test for the first year) 9. Overnight pass information 10. Dates of Client's entry and completion or termination from the facility, including circumstances of their discharge. 11. A copy of the Recovery Residence facility rules and Client Intake forms signed and dated by the Client upon entry into the Recovery Residence facility. 12. Client's files are restricted access to persons who have a legitimate need to view them. Only Stephouse Recovery staff and people that have been added to a release of information that is signed by the client will have access. RECORDS MANAGEMENT AND MAINTENANCE A. Stephouse Recovery, its officers, agents, employees, and sub-contractors shall, throughout the term of the Contract Agreement, prepare, maintain, and manage records appropriate to the services provided and in accordance with the Agreement and all applicable requirements. 1. Stephouse Recovery shall maintain records that are adequate to substantiate the services for which claims are submitted for reimbursement under the Agreement and the charges thereto. Such records shall include, but not be limited to, individual patient charts and utilization review records. 2. Stephouse Recovery shall keep and maintain records that include referral and intake documents, client identification, insurance information and authorizations to share -109- Page 24 of 43 information. Additional records include client drug screening, and supporting logs as required by OCHCA. 3. Stephouse Recovery shall maintain books, records, documents, accounting procedures and practices, and other evidence sufficient to reflect properly all direct and indirect cost of whatever nature claimed to have been incurred in the performance of the Agreement and in accordance with Medicare principles of reimbursement and GAAP. 4. Stephouse Recovery shall ensure the maintenance of medical records required by §70747 through and including §70751 of the CCR, as they exist now or may hereafter be amended, the medical necessity of the service, and the quality of care provided. Records shall be maintained in accordance with §51476 of Title 22 of the CCR, as it exists now or may hereafter be amended. B. Access to client records and information is restricted by job title, individual need to know or need to complete job duties and contract requirements. Non-routine access to client records must be approved by Stephouse Director or Compliance Officer. These include, but are not limited to the following: 1. Research 2. Subpoena 3. Court Orders 4. Mandatory Reporting 5. Accreditation Surveys 6. Law Enforcement 7. Government Agencies C. Stephouse Recovery shall implement and maintain administrative, technical, and physical safeguards to ensure the privacy of PHI and prevent the intentional or unintentional use or disclosure of PHI in violation of the HIPAA, federal, and state regulations. Stephouse Recovery shall mitigate to the extent practicable, the known harmful effect of any use or disclosure of PHI made in violation of federal or state regulations and/or OCHCA policies. D. Stephouse Recovery participant, client, and/or patient records shall be maintained securely. Stephouse Recovery shall maintain participant, client, and/or patient records and has established and implements written record management procedures. E. Stephouse Recovery shall retain all financial records for a minimum of ten (10) years from the termination of the Agreement unless a longer period is required due to legal proceedings such as litigations and/or settlement of claims. E. Stephouse Recovery shall retain all client and/or patient medical records for ten (10) years following discharge of the participant, client, and/or patient. F. Stephouse Recovery shall make records pertaining to the costs of services, participant fees, charges, billings, and revenues available at one (1) location within the limits of the OCHCA of Orange. If Stephouse Recovery is unable to meet the record location criteria above, OCHCA may provide written approval to Stephouse Recovery to maintain records in a single location, identified by Stephouse Recovery. G. Stephouse Recovery shall notify OCHCA of any PRA requests related to, or arising out of, this Agreement, within forty-eight (48) hours. Stephouse Recovery shall provide OCHCA all information that is requested by the PRA request. H. Stephouse Recovery shall ensure all HIPAA DRS requirements are met. HIPAA requires that clients, participants and/or patients be provided the right to access or receive a copy of their DRS and/or request an addendum to their records. Title 45 CFR §164.501, defines DRS as a group of records maintained by or for a covered entity that is: 1. Medical and billing records about individuals maintained by or for a covered healthcare provider. 2. The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or -110- Page 25 of 43 3. Used, in whole or in part, by or for the covered entity to make decisions about individuals. I. Stephouse Recovery may retain client, and/or patient documentation electronically in accordance with the terms of this Agreement and common business practices. If documentation is retained electronically, Stephouse Recovery shall, in the event of an audit or site visit: 1. Have documents readily available within twenty-four (24) hour notice of a scheduled audit or site visit. 2. Provide auditor or other authorized individuals access to documents via a computer terminal. 3. Provide the auditor or other authorized individuals with a hardcopy printout of documents, if requested. J. Stephouse Recovery shall ensure compliance with requirements pertaining to the privacy and security of PII and/or PHI. Stephouse Recovery shall, upon discovery of a Breach of privacy and/or security of PII and/or PHI by Stephouse Recovery, notify federal and/or state authorities as required by law or regulation, and copy OCHCA on such notifications. K. Stephouse Recovery may be required to pay any costs associated with a Breach of privacy and/or security of PII and/or PHI, including but not limited to the costs of notification. Stephouse Recovery shall pay any and all such costs arising out of a Breach of privacy and/or security of PII and/or PHI. L. Stephouse Recovery shall make records pertaining to the costs of services, patient fees, charges, billings, and revenues available at one (1) location within the limits of the OCHCA of Orange. HIPAA PRIVACY AND SECURITY/NOTICE OF PRIVACY PRACTICES Stephouse Recovery intends to protect the privacy and provide for the security of PHI that may be created, received, maintained, transmitted, used, or disclosed pursuant to the Agreement in compliance with the applicable standards, implementation specifications, and requirements of HIPAA, the HITECH Act, and the HIPAA regulations as they may exist now or be hereafter amended. Stephouse Recovery understands and acknowledges that HIPAA, the HITECH Act, and the HIPAA regulations do not pre-empt any state statutes, rules, or regulations that are not otherwise pre- empted by other Federal law(s) and impose more stringent requirements with respect to the privacy of PHI. Stephouse Recovery agrees not to use or further disclose PHI from OCHCA to Stephouse Recovery other than as permitted or required by this Business Associate Contract or as required by law. Stephouse Recovery agrees to comply with the HIPAA Security Rule at Subpart C of 45 CFR Part 164 with respect to electronic PHI OCHCA discloses to Stephouse Recovery, or Stephouse Recovery creates, receives, maintains, or transmits on behalf of OCHCA. Stephouse Recovery agrees to mitigate, to the extent practicable, any harmful effect that is known to Stephouse Recovery of a Use or Disclosure of PHI by Stephouse Recovery in violation of the requirements of this Business Associate Contract. Stephouse Recovery agrees to report to OCHCA immediately any Use or Disclosure of PHI not provided for by this Business Associate Contract of which Stephouse Recovery becomes aware. Stephouse Recovery must report Breaches of Unsecured PHI in accordance with Subparagraph E below and as required by 45 CFR § 164.410. Stephouse Recovery shall ensure the continuous security of all computerized data systems containing electronic PHI OCHCA discloses to Stephouse Recovery or Stephouse Recovery creates, receives, maintains, or transmits on behalf of OCHCA. Stephouse Recovery shall protect paper documents containing PHI OCHCA discloses to Stephouse Recovery ERY, or Stephouse Recovery creates, receives, maintains, or transmits on behalf of OCHCA. These steps shall include complying with all the data system security precautions listed under Subparagraphs E, and achieving and maintaining -111- Page 26 of 43 compliance with the HIPAA Security Rule, as necessary in conducting operations on behalf of OCHCA. BREACH POLICY “Breach” means the acquisition, access, use, or disclosure of PHI in a manner not permitted under the HIPAA Privacy Rule which compromises the security or privacy of the PHI. "Breach" shall have the meaning given to such term under the IEA and CMPPA. It shall include a "PII loss" as that term is defined in the CMPPA. "Breach of the security of the system" shall have the meaning given to such term under the CIPA, CCC § 1798.29(d). a. Breach excludes: 1) Any unintentional acquisition, access, or use of PHI by a workforce member or person acting under the authority of Stephouse Recovery or OCHCA , if such acquisition, access, or use was made in good faith and within the scope of authority and does not result in further use or disclosure in a manner not permitted under the Privacy Rule. 2) Any inadvertent disclosure by a person who is authorized to access PHI at Stephouse Recovery to another person authorized to access PHI at Stephouse Recovery, or organized health care arrangement in which OCHCA participates, and the information received as a result of such disclosure is not further used or disclosed in a manner not permitted under the HIPAA Privacy Rule. 3) A disclosure of PHI where Stephouse Recovery or OCHCA has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retains such information. b. Except as provided in paragraph (a) of this definition, an acquisition, access, use, or disclosure of PHI in a manner not permitted under the HIPAA Privacy Rule is presumed to be a breach unless Stephouse Recovery demonstrates that there is a low probability that the PHI has been compromised based on a risk assessment of at least the following factors: 1) The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification; 2) The unauthorized person who used the PHI or to whom the disclosure was made; 3) Whether the PHI was actually acquired or viewed; and 4) The extent to which the risk to the PHI has been mitigated. BREACH DISCOVERY AND NOTIFICATION 1. Following the discovery of a Breach of Unsecured PHI , Stephouse Recovery shall notify OCHCA of such Breach, however both parties agree to a delay in the notification if so advised by a law enforcement official pursuant to 45 CFR § 164.412. a. A Breach shall be treated as discovered by Stephouse Recovery as of the first day on which such Breach is known to Stephouse Recovery or, by exercising reasonable diligence, would have been known to Stephouse Recovery. b. Stephouse Recovery shall be deemed to have knowledge of a Breach, if the Breach is known, or by exercising reasonable diligence would have known, to any person who is an employee, officer, or other agent of Stephouse Recovery, as determined by federal common law of agency. 2. Stephouse Recovery shall provide the notification of the Breach immediately to the County Privacy Officer. Stephouse Recovery’s notification may be oral but shall be followed by written notification within 24 hours of the oral notification. 3. Stephouse Recovery’s notification shall include, to the extent possible: a. The identification of each Individual whose Unsecured PHI has been, or is reasonably believed by Stephouse Recovery to have been, accessed, acquired, used, or disclosed during the Breach; b. Any other information that OCHCA is required to include in the notification to Individual under 45 CFR §164.404 (c) at the time Stephouse Recovery is required to notify OCHCA or promptly thereafter as this information becomes available, even after the regulatory sixty (60) day period set forth in 45 CFR § 164.410 (b) has elapsed, including: -112- Page 27 of 43 1) A brief description of what happened, including the date of the Breach and the date of the discovery of the Breach, if known; 2) A description of the types of Unsecured PHI that were involved in the Breach (such as whether full name, social security number, date of birth, home address, account number, diagnosis, disability code, or other types of information were involved); 3) Any steps Individuals should take to protect themselves from potential harm resulting from the Breach; 4) A brief description of what Stephouse Recovery is doing to investigate the Breach, to mitigate harm to Individuals, and to protect against any future Breaches; and 5) Contact procedures for Individuals to ask questions or learn additional information, which shall include a toll-free telephone number, an e-mail address, Web site, or postal address. 4. COUNTY may require Stephouse Recovery to provide notice to the Individual as required in 45 CFR § 164.404, if it is reasonable to do so under the circumstances, at the sole discretion of OCHCA. 5. In the event that Stephouse Recovery is responsible for a Breach of Unsecured PHI in violation of the HIPAA Privacy Rule, Stephouse Recovery shall have the burden of demonstrating that Stephouse Recovery made all notifications to OCHCA consistent with this Paragraph E and as required by the Breach notification regulations, or, in the alternative, that the acquisition, access, use, or disclosure of PHI did not constitute a Breach. 6. Stephouse Recovery shall maintain documentation of all required notifications of a Breach or its risk assessment under 45 CFR § 164.402 to demonstrate that a Breach did not occur. 7. Stephouse Recovery shall provide to COUNTY all specific and pertinent information about the Breach, including the information listed in Section E.3.b.(1)-(5) above, if not yet provided, to permit COUNTY to meet its notification obligations under Subpart D of 45 CFR Part 164 as soon as practicable, but in no event later than fifteen (15) calendar days after Stephouse Recovery’s initial report of the Breach to OCHCA pursuant to Subparagraph E.2 above. 8. Stephouse Recovery shall continue to provide all additional pertinent information about the Breach to OCHCA as it may become available, in reporting increments of five (5) business days after the last report to OCHCA. Stephouse Recovery shall also respond in good faith to any reasonable requests for further information, or follow-up information after report to OCHCA, when such request is made by OCHCA. 9. If the Breach is the fault of Stephouse Recovery, Stephouse Recovery shall bear all expense or other costs associated with the Breach and shall reimburse OCHCA for all expenses OCHCA incurs in addressing the Breach and consequences thereof, including costs of investigation, notification, remediation, documentation or other costs associated with addressing the Breach. INTAKE POLICY AND PROCEDURE Admission Criteria Stephouse Recovery must receive an email from the OCHCA gatekeeper. Once a client arrives, we fax the Referral form back to HCA. Intake means the initial face-to-face meeting between a Client and Stephouse Recovery staff in which specific information about the Client is gathered, including waiver of confidentiality and other required documents signed at the time of the Client's initial intake into the Recovery Residence facility. This is completed to permit disclosure of designated information about the Client to HCA, Treatment Provider, Courts, Orange County Probation Department, (OCPD), Parole Department, Public Defender, and/or District Attorney. Intake Prescreening Policy, Readmission, Intake and Discharge Criteria Policy and Procedure It is the policy of Stephouse Recovery to have every client goes through an intake process upon arrival. It is the policy of Stephouse Recovery to maintain consistent Admission, Readmission, and Intake Criteria. *If a client is deemed to need a higher level of care, Stephouse Recovery will not accept the client into -113- Page 28 of 43 the program and will refer the client back to OCHCA* Procedure All clients requesting admission are scheduled for an intake session with designated staff. The staff will conduct a face-to-face interview and is responsible for the appropriate assessment collected on the intake form and reviewed by the intake staff. Criteria to qualify for enrollment includes ▪ A willingness to continue sobriety ▪ Abstinence from drugs and alcohol for at least one month prior to admittance ▪ Successful completion of a detox and treatment program. ▪ No one who is under the influence or displaying questionable or dangerous behaviors will be admitted to Stephouse Recovery. OCHCA requires that staff are trained in Recognizing Symptoms Requiring Appropriate Referral. ▪ Residents must be capable of living independently. Should a referral be denied admission, the person will be referred back to the OC HCA Gatekeeper for more appropriate placement. During the intake process, the intake staff will perform the following functions: ▪ Review client rights ▪ Review Stephouse Recovery policies and procedures ▪ Obtain the consent and appropriate release of information OUTPATIENT PARTICIPATION POLICY Clients that include mandatory participation, either in a COUNTY-approved outpatient treatment program and/or the Day Reporting Center (DRC), must comply or be discharged. Exceptions to aftercare linkages must be approved by THE COUNTY OF ORANGE. Clients must attend outpatient meetings (AA, NA, etc.) as required by the referring agency. Staff will collect client meeting cards weekly on Sunday evenings at the home. If the client is unavailable on Sunday evening, it is their responsibility to arrange for staff to receive the cards prior to Sunday evening. Clients are required to complete meeting cards as proof of attendance and the cards must be signed by the client’s meeting counselor or group leader. Periodically Stephouse Recovery will contact the program where the client is attending meetings, requesting verification of attendance. Therefore, at the time of intake, Stephouse Recovery requires a signed release of patient information form from the client for the outpatient or day reporting program. A client’s file must have the names of the client’s current outpatient care option (treatment facility or Day Reporting Center) and signed meeting cards showing proof of attendance. OUTPATIENT TREATMENT PARTICIPATION COLLECTION • Client must enroll in the required Outpatient approved treatment within 30 days of intake. • Newly admitted clients are required to provide a letter of proof of enrollment. • If clients are not enrolled in Outpatient treatment within 30 days, they are referred back to the screener and discharged. The client's probation officer will be contacted. • Stephouse administration will periodically contact the client’s Outpatient facility to confirm client attendance. • Clients are given meeting logs to document Outpatient therapy; all therapy must be added, including online therapy. • Clients turn in meeting logs at the end of each month. TRACKING PROCEDURE The client’s file must have the names of the Client's current outpatient care option (treatment facility or Day Reporting Center) and keep proof from the client of attending. -114- Page 29 of 43 Clients must attend outpatient meetings (AA, NA, etc.) as required by the referring agency. Staff will collect client meeting cards weekly on Sunday evenings at the home. If the client is unavailable Sunday evening, it is their responsibility to arrange for staff to receive the cards before Sunday evening. The completed meeting cards are proof of attendance. The clients receive the meeting cards from the outpatient treatment program, Day Reporting Center (DRC), court, or probation officer. CLIENT SIGN-IN/OUT LOG - All clients must sign in/out when entering or leaving the residence. Failure to do so will result in a write-up, or discharge from the program as needed. Stephouse Recovery shall provide logs for all clients that will include the following information: • Client name and signature when leaving and signature again when returning • Date and time leaving the Recovery Residence facility • Estimated time of return to the facility • Location and telephone number where the c lient may be reached The Stephouse Recovery shall achieve performance objectives, tracking and reporting Performance Outcome Objective statistics in monthly programmatic reports, as appropriate. Revisions to objectives and services may be implemented by mutual agreement between STEPHOUSE RECOVERY and THE COUNTY OF ORANGE. Stephouse will submit timely and accurate monthly reports via a HIPAA- compliant link online. Stephouse Recovery shall provide an effective sober living program to Clients with identified alcohol and/or drug problems as measured by Employment and Housing Linkage Rates. • Employment Rate: Eighty Percent (80%) of all clients successfully completing the program shall obtain employment, be enrolled in school, or participate in regular volunteer activities by discharge. Clients who are enrolled as full -time students or are deemed physically or mentally disabled by a certified physician, and who have volunteered for more than ten (10) hours per week in the community are considered employed. The employment rate shall be calculated by the number of clients who obtained employment (as defined above) at the completion of Recovery Residence Services divided by the number of clients completing Recovery Residence Services during the evaluation period. • Housing Linkage Rate: Eighty Percent (80%) of all clients shall be linked to stable housing upon completion of Recovery Residence Services. Housing Linkage Rate shall be calculated by the number of clients transitioning to stable housing upon completion of Recovery Residence Services divided by the number of Clients completing Recovery Residence Services during the evaluation period. Bed Day means one (1) calendar day during which Stephouse Recovery provides Recovery Residence Services as described in Exhibit A of the Agreement. A Bed Day will include the day of admission but not of discharge. If admission and discharge occur on the same day, one (1) Bed Day will be charged. Probation and the HCA staff are to be notified as soon as possible upon a client's discharge. CLIENT RELAPSE POLICY If a client relapses, staff will complete an incident report and notify the Program Monitor and the client’s Probation Officer. Stephouse Recovery management will decide if the client can stay in the program. If the client does stay in the program, he or she will be placed on a behavioral contract with zero tolerance for any further violation of Stephouse rules. If the client does not stay in the program, he or she will be referred by Stephouse to a different facility/program. Please see the Discharge Policy and Procedure for additional actions for relapsed clients. -115- Page 30 of 43 DISCHARGE PROCEDURES FOR STAFF Procedure A client has completed the program when they have used their maximum allotted time or reached their goals for transition. However, when a client leaves Stephouse Recovery for any reason, the staff must fax back the original Client Referral Form to the OCHCA Gatekeeper. The bottom portion of the form must include the discharge date, complete or incomplete, and the reason for leaving. Clients successfully completing the program should complete and sign an AB109 Discharge Plan form. Staff should also complete the Stephouse Recovery Discharge Form to assist in reporting information to OCHCA. No signature is required from clients who are terminated before completion. Failure to comply with Stephouse policies signed at intake may result in a written warning or termination from the program. Infractions will be documented in the client's record, and a behavioral contract will accompany the written warning. If the client is terminated, the OCHA Gatekeeper will be notified immediately via fax, and the OCHA Program Officer will be notified by email. When applicable, the client's Probation Officer and/or emergency contact will also be notified. Housing Resources shall be provided to clients regardless of completion status. In the case of homelessness, the appropriate city agency will be contacted to determine if services are available for the client. Should transportation to treatment or a shelter be necessary, Stephouse will provide. In addition, there may be circumstances where law enforcement may be called, and legal action taken against the client. If a client discharges from the program and does not collect personal belongings, the items will be held for seven (7) days (excluding food products) and then discarded or donated to charity. Clients terminated from the program must be sober before they enter Stephouse property. Each client should receive a housing resource guide upon discharge. Cause for Discharge Criteria • If a client needs a higher level of care. • The client has not returned, and no contact has been made after three (3) days. • Theft of any kind. Theft may also result in legal proceedings. • Threatening or dangerous behavior. • Behavior that is not conducive to recovery. Unacceptable behavior includes but is not limited to sexual activity on the premises, fighting, stealing, lying, etc. • Confrontational behavior, harassment, and being a constant nuisance to other clients or staff. • Continuous poor behavior and attitude toward staff or other clients. • Positive results/refusal of urinalysis, breathalyzer, or any other drug test. Refusal to test is equivalent to a POSITIVE test. • DRUG/ALCOHOL AND/OR PARAPHERNALIA on the premises. • Taking or possessing prescription drugs that are prescribed to someone else. • Vandalism or other deliberate abuse of house property. • Sexual harassment to residents, vendors, staff, or others. • Violating the no-smoking policy. • Leaving after curfew without permission. • Illegal activities of any kind. • Violence or threats of violence. • Weapons possession. • Failure to sign in/out when entering or leaving the residence. This may result in a written client warning or discharge from the program as needed. • Refusing to allow a search of personal belongings, room, or person. In addition, clients are required to maintain an appropriate noise level. Loud noises of any kind are prohibited; please keep noises to a minimum. The first offense will result in a verbal warning and will be documented in the client's record. Repeated violations may result in discharge from the program. -116- Page 31 of 43 These causes for termination are not an exhaustive list. Stephouse Management reserves the right to consider all circumstances, behaviors, issues, etc., for appropriate action. All terminations are up to the staff’s discretion. Once a client is discharged, they are not allowed to return to the facility except to retrieve personal belongings. Arrangements to retrieve belongings should be made in advance with Stephouse Recovery staff. RECORD RETENTION POLICY Following a discharge, Stephouse Recovery shall retain all participant, client, and patient medical records for ten (10) years, except non-emancipated minors for whom records must be kept for at least one (1) year after such children have reached the age of eighteen (18) years, or for ten (10) years after the last date of service, whichever is longer. This information will also include dates of the client's entry and completion or termination from the facility, including the circumstances of their discharge. DENIED ADMISSION POLICY If a client is deemed to need a higher level of care, Stephouse Recovery has the discretion not to accept the client into the program and will refer the client back to OCHCA. A client can be denied admission by Stephouse Recovery for felonious sex crimes, arson, or other violent felonies. If a client has a positive drug test at admission, Stephouse Recovery has the discretion to not accept the client into the program and will refer the client back to OCHCA. Stephouse Recovery complies with all State and Local laws and penal codes regarding registered sex offenders. A referral may be denied admission if the offender does not meet the legal requirements. ALTERNATIVE REFERRAL POLICY In the event of admission denial, the Stephouse Recovery or designee will provide referrals to facilities or services appropriate to the client’s presenting problems. The original referral form will be faxed back to OCHA notifying them of the admission denial. CLIENT ELIGIBILITY Admission to Stephouse Recovery is open to AB 109 offenders with substance use disorders who were released either on PCS (Post-Release Community Supervision) or on SR (Supervised Release) and who have no available housing. You must be an adult 18 and over and be referred by the Orange County Health Care Agency. The AB 109 Sober Living Services is up to a four (4) month program. Stephouse Recovery sober living has a policy that will not discriminate in provision of services on the basis of ethnic group identification, religion, age, sex, sexual preference, race, disability pursuant to the Title IV of the Civil Rights Act of 1964 (Section 20000d, Title 42, United States Code); Section 11135 of California Government Code; and for recipients of financial assistance of the Rehabilitation Act of 1973 (Section 794. Title 29, United States Code); and Chapter 6 (Commencing with Section 10800) Division 4, Title 9 of the California Code of Regulations in accordance with all state and federal laws and regulations. The program will provide clients with shared, safe, comfortable, and healthful accommodation. Assurance of provision and recognition of personal rights and the right to confidentiality as provided for in Title 42, Section 2.1 through 2.67-1, Code of Federal Regulations, effective August 1, 1975. CLIENT REQUIREMENTS In order to remain in good standing at Stephouse Recovery, all clients must…… • Participate in structured daily activities such as house cleaning and basic household operations. • Agree to follow StepHouse Recovery Center's Signing In/Out Policy. -117- Page 32 of 43 • Agree to follow StepHouse Recovery Center's House Rules. • Agree to follow StepHouse Recovery Center's Schedule Policy. • Agree to follow StepHouse Recovery Center's Transportation Policy. • Agree to follow StepHouse Recovery Center's Food Policy. • Agree to adhere to StepHouse Recovery Center's Drug/Alcohol Screening Policy. • Agree to follow StepHouse Recovery Center's Meetings Policy. • Agree to follow StepHouse Recovery Center's Authority Policy. • Agree to follow StepHouse Recovery Center's Non-Smoking Policy. • Agree to follow StepHouse Recovery Center's Good Neighbor Policy. • Agree to follow StepHouse Recovery Center's Medication Policy. • Agree to follow StepHouse Recovery Center's Visitation Policy. *Note: These policies are outlined in the AB 109 Sober Living Services Participant Handbook THE FOLLOWING RELATES TO SOBRIETY, CONDUCT, AND RESPONSIBILITIES WHILE AT A STEPHOUSE RECOVERY RESIDENCE: • Clients must maintain total abstinence from any mind/mood altering chemicals, alcohol, and/or drug. • No paraphernalia (syringes, papers, pipes, spoons, etc.) associated with drugs on premises. • NO EXCEPTIONS Cough syrup with alcohol content is prohibited for client safety and sobriety. • Abide by the curfew for clients, which is 10:00 P.M weekdays and 11:00 P.M weeknights and holidays. All clients must follow curfews unless other arrangements have been made in advance with management. • Take directions from all staff at the facility. • Overnight passes may be given to clients after they become eligible. • Clients are to sign in/sign out when leaving the facility. • All clients are subject to random drug and alcohol screens. • Client must notify staff of any communicable disease. STEPHOUSE RECOVERY’S POLICIES AND PROCEDURES The following policies and procedures are shared with the client at intake AUTHORITY POLICY StepHouse Recovery shall recognize the authority of the Orange County Probation Department (OCPD) as officers of the court and shall extend cooperation to OCPD within the constraints of state and federal laws and regulations. StepHouse Recovery shall operate in accordance with Local, State, and Federal laws and regulations. StepHouse Recovery has an open-door policy with law enforcement, probation/parole, and court services programs. All clients agree to be respectful to all. CLEANING POLICY Be considerate to others. Practice good hygiene by showering regularly, washing clothes and bedding regularly, and keeping personal living areas clean and orderly. Clean up after yourself; especially after using the shared common areas (bathroom, living room, patio, yards, garage areas, kitchen, fridges, etc.). All common areas in housing are to be shared and treated with respect and cleanliness. -118- Page 33 of 43 Cleaning supplies are provided to the facilities. Mandatory cleaning days will be scheduled by staff biweekly on Sundays. CLIENT CONFIDENTIALITY POLICY I shall respect and maintain the confidentiality of all discussions between staff and other clients in connection with group meetings where clients share personal information. I understand that I am legally prohibited from posting or sharing pictures, videos, or information about other clients, discussions, or activities online in any format (including, but not limited to email, websites, message boards, blogs, and social networking platforms). I understand that these are the conditions of my admission to StepHouse Recovery. Any breach of the Client Confidentiality Agreement may result in immediate discharge from StepHouse Recovery. I further understand that my personal file may be audited by StepHouse Recovery’s authorized personnel for the purpose of monitoring quality, performance, and compliance. All information will be kept confidential and in accordance with the Federal Confidentiality Regulations. CLIENT SIGN-IN/OUT POLICY – CLIENT SCHEDULES All clients must sign in/out when entering or leaving the residence. Failure to do so will result in a write -up, blackout, or discharge from the program as needed. StepHouse Recovery shall provide logs for all clients that will include the following information: ✔ Client name and signature when leaving and signature again when returning ✔ Date and time leaving the Recovery Residence facility ✔ Estimated time of return to the facility ✔ Location and telephone number where the client may be reached. StepHouse Recovery shall also receive a schedule from the client for treatment, work, school, or other activities. The client shall be required to notify StepHouse Recovery staff of any change to their schedule. The schedule is maintained on a calendar monitored by staff at each home. OUTPATIENT PARTICIPATION POLICY Clients who are required to participate in either an Orange County approved outpatient treatment program and/or a Day Reporting Center (DRC) must comply or be discharged. Exceptions to the mandatory participation must be approved by the county of Orange and provided to Stephouse Recovery in writing. OCHCA requires that all clients attend outpatient meetings ((SMART recovery, 12-Step program, etc.). Staff will collect client meeting logs weekly on Sunday evenings. If the client is unavailable on Sunday evening, they must arrange for staff to receive the logs before Sunday evening. Clients are required to complete meeting logs as proof of attendance, which must be signed by the client’s meeting counselor or group leader. Periodically Stephouse Recovery will contact the program where the client attends meetings, requesting attendance verification. Therefore, at the time of intake, Stephouse Recovery requires a signed release of patient information form permitting the outpatient meeting agency to share information with Stephouse. -119- Page 34 of 43 CURFEW/OVERNIGHT POLICY Clients must be back by curfew: Weekdays- 10:00 PM. Weekends and Holidays- 12:00 AM. All clients must follow curfews unless other arrangements have been made in advance with management (i.e., overnight pass, working past curfew, etc.). Clients must be with StepHouse Recovery for a minimum of 30 days and have no behavioral issues to qualify for an overnight pass. Approval must be requested in writing to the StepHouse office at least 48 hours in advance and is up to the staff’s discretion. Clients may obtain overnight passes for a maximum of two (2) weekends or four (4) nights per month. Leaving the house after curfew hours may be grounds for termination from the program. Curfew violators will be placed on a behavioral contract and required to pass a drug test prior to returning to housing. The client agrees that they are subject to discharge if they leave StepHouse Recovery overnight without a pass. DISCHARGE/TERMINATION POLICY Client has completed the program when they have used their maximum allotted time or reached their goals for transition. Staff will complete a Discharge Form to document the circumstances of the client leaving sober living. Clients are not required to sign the discharge form. Failure to comply with StepHouse policies signed at intake may result in a written warning or administrative termination from the program. Infractions will be documented in the client's record, and a behavioral contract will accompany the written warning. The client's Probation/Parole Officer will be notified of termination when applicable. In addition, there may be circumstances where law enforcement may be called, and legal action taken against the client. If a client discharges or is terminated from the program and does not collect personal belongings, the items will be held for seven (7) days (excluding food products) and then discarded or donated to charity. Clients terminated from the program must be sober before they enter StepHouse property. Each client should receive a housing resource guide upon discharge. Stephouse Recovery will assist discharged clients in securing safe, temporary shelter in the event of immediate discharge. Residents who have relapsed and under the influence may be transported to Be Well Orange Campus or College Hospital Costa Mesa. Cause for Termination from the Program ● If a client needs a higher level of care than provided at StepHouse Recovery. The client will be referred to OCHCA. ● The client has left the residence and no contact has been made after three (3) days (unless other arrangements have been made) ● Theft of any kind. Theft may also result in legal proceedings. ● Threatening or dangerous behavior. ● Behavior that is not conducive to recovery. Unacceptable behavior includes but is not limited to sexual activity on the premises, fighting, stealing, lying, etc. ● Confrontational behavior, harassment, and being a constant nuisance to other clients or staff. ● Continuous poor behavior and attitude toward staff or other clients. -120- Page 35 of 43 ● Positive results/refusal of urinalysis, breathalyzer, or any other drug test. Refusal to test is equivalent to a POSITIVE test. ● DRUG/ALCOHOL AND/OR PARAPHERNALIA on the premises. ● Taking or possessing prescription drugs that are prescribed to someone else. ● Vandalism or other deliberate abuse of house property. ● Sexual harassment to residents, vendors, staff, or others. ● Violating the no-smoking policy. ● Leaving after curfew without permission. ● Illegal activities of any kind. ● Violence or threats of violence. ● Weapons possession. ● Failure to sign in/out when entering or leaving the residence. This may result in a written client warning or discharge from the program as needed. ● Refusing to allow a search of personal belongings, room, or person. In addition, clients are required to maintain an appropriate noise level. Loud noises of any kind are prohibited; please keep noises to a minimum. The first offense will result in a verbal warning and will be documented in the client's record. Repeated violations may result in discharge from the program. These causes for termination are not an exhaustive list. Stephouse Management reserves the right to consider all circumstances, behaviors, issues, etc., for appropriate action. All terminations are up to the staff’s discretion. Once a client is discharged, they are not allowed to return to the facility except to retrieve personal belongings. Arrangements to retrieve belongings should be made in advance with StepHouse Recovery staff. DISCRETION POLICY The client understands that they are entering independent sober living. Privacy is limited and space is shared. Stephouse Recovery staff will conduct bed checks and will be entering bedrooms regularly. StepHouse Recovery staff reserves the right to interpret and apply the rules to meet the needs of each client effectively and within reason. Staff will use their best judgment with events and circumstances as they occur. Stephouse Management reserves the right to change or make additions to StepHouse Recovery Policies and Procedures at any time. It is within StepHouse Recovery’s discretion to make amendments or modifications to any of the following: ● Rules and Regulations ● Policies ● Room Assignments ● Food Requirements ● Schedules ● Supervision ● Chore Assignments ● Testing ● Discharge Clients who violate any StepHouse Recovery Policies or Procedures agree to the decisions and consequences deemed necessary by the staff. DRUG/ALCOHOL POLICY Alcohol, illegal drugs, or non-prescribed drug use, distribution, and/or possession are strictly prohibited. Cough syrup or mouthwash with alcohol content is prohibited. A client must have total abstinence from any mind/mood-altering chemicals and/or drugs. -121- Page 36 of 43 No paraphernalia (syringes, papers, pipes, spoons, etc.) associated with drugs on-premises. No association with any active drug or alcohol offender(s), nor frequent places where drugs are sold, used, or are accessible. Any infraction may result in the client being put on a standout*, behavioral contract, or discharged. (*Standout- A specified number of days when a client is banned from the house). SUPPORT STAFF Staff is responsible for the supervision of all clients residing in the facility. Staff shall be responsible for ensuring the safety of the buildings and grounds and maintaining compliance of clients and staff with facility rules. Whenever StepHouse Recovery Staff is not present at the facility, a designated facility staff person shall be on-call to respond and arrive at the facility. StepHouse Recovery shall post the contact telephone number of designated on-call staff. The staff will randomly be on sight at the facility to perform UAs/breathalyzers and conduct random searches of the client’s rooms, personal property, and belongings. EMPLOYMENT/SCHOOL/VOLUNTEERING POLICY StepHouse Recovery requires all clients to be employed, seeking employment, attending school or volunteering during the duration of their program. Verification of employment, interviews, applications, or volunteer hours is required weekly. Proof of school enrollment is also required. Failure to comply with this policy can result in discharge from the program. GOOD NEIGHBOR POLICY A top priority for StepHouse Recovery is to ensure that the occupants of our homes are considerate of the neighbors and respectful of the neighborhoods in which they reside. The following protocol should always be followed by clients and staff to ensure that the community and StepHouse Recovery maintain a healthy relationship. StepHouse Recovery provides contact information of our managerial staff to the bordering neighbors (located behind, to the left, to the right, as well as across the street of each recovery residence). We provide bordering neighbors with an "Introductory Letter" informing them of our presence in the community and our mission and efforts to help those in recovery make their fresh start in a safe and sober environment. "Introductory Letters" can be requested from staff. Should a neighbor contact a house manager with a complaint regarding our home or its occupants, it is the responsibility of the house manager to pass this information to Management immediately, failure to do so will result in a written warning. Management will respond to the complaint within 12 hours to let the concerned neighbor know that the complaint was received, and we will investigate and address the issue as the situation warrants. To maintain a clean presentation of the house and grounds, gardening will take place bi-weekly by a paid landscaping company. Management will also conduct outside maintenance as needed. Clients may not leave personal belongings, bicycles, trash, or other disposed of items at the front of the house. A monthly checkup by the Director will be made, and the current condition of the home and its grounds will be documented. Clients are required to abide by the StepHouse Recovery House Rules. Clients are expected to maintain an appropriate noise level and always behave appropriately. Smoking and vaping are permitted only in designated areas (posted) as outlined in the house rules. Cigarettes are to be disposed of in an appropriate manner. Clients are expected to maintain a clean environment and never litter. Staff and clients are responsible for setting trash cans out on the curb and bringing them in on the assigned trash day. -122- Page 37 of 43 Contact Information: Stephouse Recovery (888) 923-7623 info@stephouserecovery.com Orange County Healthcare Agency Monica Curran mcurran@ochca.com (714) 834-2488 or Monica Cabral MoCabral@ochca.com (714) 834-2027 HOUSE RULES POLICY Payments and tenure (Private Pay only) ● StepHouse Recovery requires a one-month commitment to housing. Clients may stay for as long as they feel they need structure and accountability in their life. ● Clients may move out of the housing at any time without a refund. ● There are NO REFUNDS. ● Payment is due on the first day of each month. Facility ● Accept the facility “as is”. ● The client understands they reside in a congregate housing situation, not an exclusive unit or space. ● Become familiarized with escape routes, safe gathering locations, and the need for a safe location headcount. ● It is encouraged for clients not to bring anything of high value to the facility or to keep it on their person otherwise. StepHouse Recovery is not responsible for lost, stolen, or damaged property. Clients bringing items of monetary or sentimental value to the facility are doing so at their own risk. ● No personal refrigerators, microwaves, coffee pots, heaters, furniture, candles, or excessive property is allowed. ● Moving rooms: ○ Clients may request to move rooms but are only allowed to move with permission of staff ■ Decisions will be based on seniority, behavioral assessment, and availability ○ Client must clean room previously occupied before moving. ○ Staff may need to move clients based on necessity. Changing a client’s room assignment is at the staff discretion. ● House meetings are scheduled by management on a need-be basis. If the client is unable to attend because of work conflicts, a manager must be notified. ● Laundry detergent/supplies and toiletries are not provided for client use. ● Internet Wi-Fi is provided at each location. Client Conduct -123- Page 38 of 43 ● No drugs, alcohol, and/or paraphernalia allow on house premises. ● All medications, including over the counter, must be held and dispensed by the clients themselves. ● Do not enter other clients’ rooms. Clients may only enter their own room and are not allowed to enter another client's bedroom. ● Clients are not allowed to fraternize with other clients. ● Do not share rental agreement information with other clients. ● All overnight passes must be requested for approval by Thursday of each week. ● Client agrees that if they leave StepHouse Recovery for an overnight without a "pass" they are subject to discharge. Personal belongings will only be held for seven (7) days (excluding food products) and then discarded or donated to charity. ● NO PETS- Pets of any kind are not permitted. ● Clients are expected to rise in the morning at a reasonable time to ensure they are dressed, bed made, immediate area cleaned, and house chores completed by 11 am daily. ● Assigned chores must be completed daily. ● Before leaving the house, chores must be completed, the bed must be made, and the room must be tidy. If clients have school/work/volunteering before the "11 am Chore Check", they must complete all household responsibilities before leaving. ● All clients must wear appropriate attire when in shared areas of the facility and/or in the presence of other residents and staff. Appropriate attire includes shirts and pants/shorts, and dresses. ● CURFEW, clients must be in the house by 10 PM on weekdays and 11 PM on weekends and holidays. ● Be considerate to others. Keep music and television audio so as not to disturb other clients. Pick up after yourself, leaving microwaves, common areas, and bathrooms clean for the next person. ● Shower daily, maintain personal hygiene, and wash your clothes regularly. ● Bedding must be washed weekly. ● NO SMOKING/VAPING inside of or in front of the house. SMOKING/VAPING is only permitted in designated areas. ● DO NOT LEAVE BURNING CIGARETTES UNATTENDED. ● Empty ashtrays as needed. ● Clients agree not to have any contact with ex-clients that have been discharged due to relapse or behavioral infractions. ● NO STEALING! Respect others' property. Theft is cause for immediate discharge and may result in legal proceedings. ● DO NOT TOUCH THE MAIL. The operations coordinator is the only person allowed to bring the mail in from the mailbox. ● All clients must attend at least five 12-Step meetings and scheduled house solutions meetings. ● Threatening or dangerous behavior and/or deliberate abuse of house property will be cause for immediate discharge and may result in legal proceedings. ● Sexual harassment is strictly prohibited and will result in automatic discharge from the program. The client’s Parole/Probation Officer and law enforcement will be notified. ● Clients must notify staff of any communicable disease. ● If you see something, say something. The purpose of sober living is to provide a supportive environment free from alcohol and drugs. Clients play a vital role in keeping each other safe and sober. Staff should be informed of threatening or dangerous behaviors of others, drug or alcohol use, housemates’ lack of participation in house chores, etc. ● In the event of an emergency dial 911. Staff should also immediately be notified. Daily Structured Activities Clients are required to engage in daily activities that should be discussed with their outpatient provider. Clients will be assigned household duties, including but not limited to house cleaning and basic household operations. Assigned duties must be completed daily. -124- Page 39 of 43 The client agrees to work on a program of recovery to better their lives in the form of their choosing. StepHouse Recovery highly recommends attending celebrate recovery, parenting classes, life skill classes, private counseling, and many other community-based organizations to better themselves. The client agrees and understands that a condition for being at StepHouse Recovery is to be gainfully employed, actively seeking work, in treatment, attending school, or other activities to enhance the client’s future. Staff will provide resources, assistance, and support for clients to find work, register for school, attend appropriate self-help program meetings, and volunteer in the community. MAIL AND PACKAGE DELIVERY POLICY StepHouse Recovery and staff are not responsible nor liable for mail or packages that clients choose to have delivered to a recovery residence. Do not open any packages not addressed to you. MEALS/FOOD POLICY StepHouse Recovery will provide food during the week. It is the client’s decision on whether they wish to consume the food provided. Clients are not allowed to keep any food in their rooms. All food must be kept in the kitchen or designated pantry space. Only water bottles are allowed in clients’ rooms. Clients are required to clean up after themselves. Personal items, laundry, towels, and the like should not be left in the common areas of the house. Do not leave dishes in the sink or any other areas of the house, including rooms. Clean and stow dishes, utensils, and cookware in their allocated spaces. Clean the counters and stove after use. Clean the microwave as needed, especially if you spill something. Food logs must be filled out on Sunday for the week prior. MOTOR VEHICLE (INCL. MOTORCYCLE) POLICY ● Clients driving a motor vehicle or motorcycle must possess and provide copies of a current California Driver's License, proof of insurance, and registration. ● Clients are not allowed to ride in the car of another client or allow another client to drive their car. ● All vehicles must be insured and properly registered, and the client must have a valid driver's license. ● Auto repair on the premises is not permitted without prior management permission. ● Clients are allowed only the vehicle they are currently using, no additional vehicles are permitted. Vehicles are a privilege that may be revoked at any time due to non-compliance with program rules and expectations. NONDISCRIMINATION POLICY StepHouse Recovery does not to discriminate on the basis of race, color, national origin, religion, sex, or mental or physical disabilities, pursuant to Title VI of the Civil Rights Act of 1964 (Section 2000d, Title 42, United States Code), the Rehabilitation Act of 1973 (Section 794, Title 29, United States Code); the Americans with Disabilities Act of 1990 (Section 12132, Title 42, United States Code); Section 11135 of the California Government Code; and Chapter 6 (commencing with Section 10800), -125- Page 40 of 43 Division 4, Title 9 of the California Code of Regulations. Any person who believes they or someone else has been subjected to discrimination based on race, national origin, sex, age, or disability may file a grievance under the following procedure. It is against the law for StepHouse Recovery to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. This policy applies to employees, contractors, vendors, clients, and all who interact with Stephouse Recovery. OPIOID OVERDOSE EMERGENCY TREATMENT POLICY StepHouse Recovery shall have available at each program site, at minimum, one Naloxone (Narcan) Nasal Spray for the treatment of known or suspected opioid overdose. In case of suspected opioid overdose, staff may administer Naloxone (Narcan) Nasal Spray and then call 911. Clients will also be shown how to administer Naloxone. **Note: Naloxone is the generic name of Narcan. Narcan is the brand name of Naloxone. PROPERTY DAMAGE POLICY The client agrees not to damage the facility, which includes the outside perimeter. Client agrees not to damage any property belonging to StepHouse Recovery which includes but is not limited to transport vehicles, appliances, and furniture. The client agrees to return any items to the facility before discharge, including linens, blankets, and towels. The client agrees if there is damage that cannot reasonably be traced back to a particular person, the cost of the damage will be shared equally among all the housemates. The client agrees to be financially responsible for all damage caused by them in any of the StepHouse Recovery facilities and transport vehicles. DRUG & ALCOHOL SCREENING POLICY Alcohol, illegal drug, or non-prescribed drug use or possession by clients or staff is strictly prohibited. Cough syrup with alcohol content is prohibited for client safety and sobriety. ALL CLIENTS MAY BE SUBJECT TO RANDOM DRUG SCREENS, BREATHALYZER TESTS AND ROOM SEARCHES. ● StepHouse shall perform random drug and/or alcohol testing on clients suspected of using substances AND at a minimum of one (1) time per month. ● All urine specimen collection shall be observed by same-sex staff. The result of the screening will be documented in the client's record. ● Clients are not allowed to open tests by themselves. Staff will open the tests and then give them to clients. ● If a test is unclear or possible contamination is suspected, the client will have to re-test within 1.5 hours after the first test was administered. If a client refuses a search or test or drugs or alcohol are found or detected, StepHouse Recovery will notify the client's probation officer (within one business day), and discharge from the program may result. Refusal to test is equivalent to a POSITIVE test. ** REMINDER** UNDER NO CIRCUMSTANCES SHALL A CLIENT WHO IS UNDER THE INFLUENCE BE ALLOWED IN THE HOUSE. If a client is found to be under the influence, management shall pack the client's property for retrieval at a later time. When the client is no longer under the influence, he can arrange to -126- Page 41 of 43 retrieve personal property with staff. The client’s property will be held for seven (7) days before StepHouse Recovery donates the items to charity. SMOKING POLICY Smoking, (including electronic cigarettes) is prohibited within the facilities; the use of tobacco and tobacco products on facility premises is allowed in the backyard or parking lot. 1. Smoking and/or vaping is prohibited in any enclosed area of StepHouse Recovery's facilities. 2. Cigarettes must be completely extinguished in receptacles or metal containers to reduce fire risk. 3. Any client violating the no-smoking policy may be discharged from the program. 4. A self-audit of the no-smoking policy will be implemented, and any violation should be reported by staff in an incident report. A monthly Health and Safety audit will be conducted to see if the no- smoking policy is being adhered to. -NO SMOKING/VAPING INSIDE OF OR IN FRONT OF THE HOUSE. SMOKING/VAPING is only permitted in designated areas. -DO NOT LEAVE BURNING CIGARETTES UNATTENDED. TRANSGENDER & GENDER IDENTITY POLICY StepHouse Recovery will not discriminate against ethnic group identification, religion, age, gender identification, sexual preferences, race, or disability. StepHouse Recovery will make every effort to ensure that all needs of transgender and non-cisgender persons are accommodated. We are committed to our clients feeling safe, supported, and comfortable. StepHouse Recovery is committed to maintaining client information in strict confidence. No client information is ever shared with other clients, including gender orientation. Transgender and non-cisgender clients are subject to the same drug/alcohol screening policy. A staff of the same gender the client has identified with will be in the room to observe urine specimen collection. GENDER-ORIENTED FACILITY POLICY StepHouse Recovery will accommodate clients according to their gender identity. Those clients identifying as male, and female will be housed in separate residences accordingly. TRANSPORTATION POLICY StepHouse Recovery shall arrange for transportation via bus vouchers, as necessary. StepHouse Recovery will also provide information regarding public transportation, how to obtain a bus pass, bus schedules, etc. If the client owns and operates a vehicle, StepHouse Recovery shall do its best to accommodate the vehicle in accordance with federal, state, and county rules and regulations. StepHouse Recovery is not responsible for transportation via clients’ cars. Choosing to ride in the car of another client or allow another client to drive your car is strongly discouraged and is done at your own risk. Clients are not permitted to drive or operate StepHouse Recovery vehicles. Clients can also use the service Veyo for non-emergency medical transportation. This service can be used for doctor’s appointments, meetings, therapy, etc. Call the number 1-833-648-7528 and mention that you are a client at StepHouse Recovery. -127- Page 42 of 43 All drivers of vehicles who are picking up or dropping off Stephouse Recovery clients must drive currently registered vehicles and hold a current driver’s license. Drivers may not impede residential traffic or block driveways and must obey all traffic laws. VISITATION POLICY StepHouse Recovery does not allow any visitation/visitors in any of the facilities. Failure to comply will result in discharge from the program and P.O. may be notified. Please note that probation officers may visit any of the residences at any time and will be granted entrance. ANY INFRACTION MAY RESULT IN BEING WRITTEN UP or TERMINATION FROM THE PROGRAM. P.O. WILL BE NOTIFIED. NO RESPONSIBILITY CLAUSE Stephouse Recovery assumes no responsibility for the client’s personal property. Stephouse is released from all liability for any loss or damage to any and all personal property. Personal property includes but is not limited to vehicles, valuables, money, jewelry, eyeglasses, hearing aids, documents, electronic devices (i.e., computers, game consoles, and tablets), and mobile devices. Clients are advised to minimize the personal property brought into residential recovery homes. All items brought to a Stephouse Recovery home are done at the client’s own risk. Locks are not permitted on bedroom doors, and there are no exceptions to this rule. The client agrees to hold harmless The StepHouse Recovery, Inc, the property owners, and any and all Service Providers/Contractors against any and all claims, demands, suits, or loss. -128- Page 43 of 43 ADDENDUM A ORANGE COUNTY SOCIAL MEDIA USE POLICY & PROCEDURE MAY 18, 2010 Added to the PDF version -129- PURPOSE SOC I A L MED I A USE County of Orange County Executive Office Information Technology County Social Media Use Policy and Procedure -130- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 1 of 14 Subject: County Social Media Use Policy Number: SM‐001 Approved By: Orange County Board of Supervisors on May 18, 2010 Effective: May 18, 2010 Last Revision: May 18, 2010 Revision No.: 1.0 I. PURPOSE The County of Orange has a business need to augment traditional communication methods with the use of social media channels. This need primarily stems from public demand and the rapid growth of social media (aka: Web 2.0) use by other local, state and federal government entities as an indication that social media can be used effectively to enhance constituent communications. The use of social media presents opportunity and risk to individual County agencies and departments, as well as the County as a whole. In general, the County supports the use of social media technology to enhance communication, collaboration and information exchange to meet business mission and goals. This document establishes countywide social media use policies, protocols and procedures intended to mitigate associated risks from use of this technology where possible. Shall the County change its direction on social media use, this policy will be revised and agency/department social media activity shall be adjusted accordingly. II. APPLICABILITY This policy applies to all County of Orange employees and approved volunteers, consultants, service providers and contractors performing business on behalf of a County agency/department. Agencies/Departments using social media technology prior to the implementation of the County’s Social Media Use Policy shall achieve full policy compliance within 90 days of the effective date of this document. -131- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 2 of 14 III. RESPONSIBILITY The County’s Social Media Policy was approved by the County Board of Supervisors on May 18, 2010. The County Executive Officer, or his designee, is responsible for facilitating the County’s Social Media Policy in compliance with established Board rules and protocols. This includes responsibility to audit agency/department use of social media and enforce policy compliance. Within the terms of this policy, Department Heads have authority to determine and establish social media activity at the agency/department program level. IV. POLICY 1. Agency/Department use of social media technology shall conform to the policies, protocols and procedures contained, or referenced, herein. 2. An agency/department’s decision to embrace social media shall be a risk‐based business decision approved by the Department Head and supported by a strong business case that considers the agency/department’s mission and goals, audience, legal risks, technical capabilities and potential benefits. 3. Access to social media networks from within the County’s IT infrastructure is limited to individuals performing official County business and to agencies/departments with sufficient information and technology security controls. 4. Department Heads, or designees, are responsible for determining who is authorized to use social media on behalf of the agency/department, and for designating appropriate access levels. 5. Agencies/Departments shall only utilize County approved social media networks for hosting official County social media sites. 6. County agency/department social media sites shall be created and maintained in accordance with County social network usage standards and with identifiable characteristics of an official County site. -132- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 3 of 14 7. Agencies/Departments are responsible for establishing and maintaining content posted to their social media sites and shall have measures in effect to prevent inappropriate or technically harmful information and links. 8. The same standards, principles and guidelines that apply to County of Orange employees in the performance of their assigned duties apply to employee social media technology use. 9. Agency/Department use of social media shall be documented and maintained in an easily accessible format that tracks account information and preserves items that may be considered a record subject to disclosure under the California’s Public Records Act or required to be retained pursuant to the Government Code. 10. Agency/Department social media sites shall be monitored regularly and prompt corrective action shall be taken when an issue arises that places, or has potential to place, the County at risk. V. PROCEDURES Policy 1 County Social Media Technology Use Agency/department use of social media technology shall conform to the policies, protocols and procedures contained, or referenced, herein. 1.1. Comply with all applicable federal, state, and county laws, regulations and policies including, but may not be limited to, copyright, records retention, California Public Records Act, First Amendment, privacy laws, employment related laws and County established Workforce, Information and Technology, eGovernment and Social Media usage policies. 1.2. Be familiar and carry‐out social media activity in accordance with the County’s Social Media Participation Guidelines, where applicable. 1.3. Establish and utilize social media in accordance with the County’s Approved Social Media Networks and Usage Standards. -133- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 4 of 14 Policy 2 Agency/Department Decision to Embrace Social Media An agency/department’s decision to embrace social media shall be a risk‐based business decision approved by the Department Head and supported by a strong business case that considers the agency/department’s mission and goals, audience, legal risks, technical capabilities and potential benefits. Agencies/Departments who choose to utilize social media shall: 2.1. Have a strong understanding of the risks associated with using social media in order to make an effective business decision. 2.2. Engage internal Agency/Department IT, Risk Management and County Counsel Representatives to assess the risks of utilizing a specific County approved social networking site in comparison with the business opportunities expected. 2.3. Establish a well thought out social media strategy. 2.4. Develop and maintain agency/department specific social media policies and procedures. HR shall be consulted to provide advisory on labor impacts. 2.5. Require authorized staff to complete social media security training. 2.6. Have security controls in place to protect County Information and Technology assets. 2.7. Designate a Social Media Coordinator responsible for overseeing the agency/department’s social media activity and policy compliance. Policy 3 Access to Social Media Networks Access to social media networks from within the County’s IT infrastructure is limited to individuals performing official County business and to agencies/departments with sufficient Information and Technology security controls. 3.1. County computers, laptops and mobile devices used to access social media sites shall have up‐to‐date software to protect against destructive technical incidents, including but may not be limited to, cyber, virus and spyware/adware attacks. -134- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 5 of 14 3.2. CEO IT and Agency/Department IT shall make a diligent effort to provide authorized users access to social media networks from within agency/department work sites. 3.3. County hosted websites shall not contain automatic feeds to uncensored social media site content. Prior to approving content for display on County websites, agencies/departments shall have monitoring protocols in place to ensure content and links are appropriate and free from harmful technical attacks. Policy 4 Authorized Use Department Heads, or designees, are responsible for determining who is authorized to use social media on behalf of the agency/department, and for designating appropriate access levels. 4.1. Social media network access shall be limited only to those with a clear business purpose to use the forum. 4.2. Appropriate access levels include identifying what sites, or type of sites, the individual is approved to use, as well as defining capability: publish, edit, comment or view only. 4.3. Only Official Spokespersons, Public Information Officers and select individuals shall have permission to create, publish or comment on behalf of a County Agency/Department. 4.4. Authorized users shall be provided a copy of the County’s social media policy and are required to acknowledge their understanding and acceptance via wet signature. Policy 5 Approved Social Media Networks Agencies/Departments shall only utilize County approved social media networks for hosting official County social media sites. 5.1. Social media networks under consideration will be reviewed and approved by the County Executive Office and CEO IT with consultation from County Counsel, HR and Risk Management when appropriate. -135- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 6 of 14 5.2. For each approved social media network, usage standards will be developed to optimize government use of the site in correlation with the County’s overall business mission and County Social Media Use Policy. 5.3. CEO IT is responsible for maintaining the list of approved social media networks and site related usage standards. 5.4. Social media networks on the approved list shall be reviewed bi‐annually for changes to terms of use agreements and/or new/expired offerings. 5.5. An agency/department may request review and approval of additional social media networks as needed. Policy 6 Official County Social Media Sites County agency/department social media sites shall be created and maintained in accordance with County social network usage standards and with identifiable characteristics of an official County site. 6.1. Social media network usage standards are accessible from CEO IT 6.2. County social media network accounts shall be created using an official County email account, when possible. 6.3. Sites shall contain visible elements that identify them as an official County of Orange site. Among other items, this includes displaying official County seals, agency/department brands, contact information and a link to agency/department websites. 6.4. County social media sites shall display, or provide a link to, the County’s social media disclaimer and any applicable eGovernment policies. Policy 7 Site Content Agencies/Departments are responsible for establishing and maintaining content posted to their social media sites and shall have measures in effect to prevent inappropriate or technically harmful information and links. 7.1. As is the case for County of Orange web sites, agencies/departments are responsible for the content and upkeep of their social media sites. -136- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 7 of 14 7.2. County websites shall remain the primary and predominant source for Internet information. 7.3. Social media content shall fully comply with the County’s eGovernment Appropriateness of Content Policy. 7.4. Information and comments shared through social media channels shall fully comply with agency/department Communications Policies and Procedures and shall not disclose confidential or proprietary information. 7.5. Sharing or posting content owned by others shall be performed in accordance with copyright, fair use and established laws pertaining to materials owned by others. This includes, but is not limited to, quotes, images, documents, links, etc. 7.6. Use of sites that are not Section 508 web accessible shall contain “simple” text links to identical material on a compliant website or other social media network. 7.7. Electronic information posted to a social media site by the County, or a member of the public, may be considered a record subject to California’s Public Record Act. 7.8. It is not intended to use social media sites in a way that guarantees the right to protected free speech. Each agency/department is responsible for monitoring postings, and taking appropriate action when necessary, to protect general site visitors from inappropriate or technically harmful information and links. 7.9. Sites that allow public comment shall inform visitors of the intended purpose of the site and provide a clear statement of the discussion topic introduced for public comment so that the public is aware of the limited nature of the discussion and that inappropriate posts are subject to removal, including but not limited to the following types of postings regardless of format (text, video, images, links, documents, etc.): 7.9.1. comments not topically related; 7.9.2. profane language or content; -137- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 8 of 14 7.9.3. content that promotes, fosters or perpetuates discrimination on the basis of race, creed, color, age, religion, gender, marital status, status with regards to public assistance, national origin, physical or mental disability or sexual orientation; 7.9.4. sexual content or links to sexual content; 7.9.5. solicitations of commerce; 7.9.6. conduct or encouragement of illegal activity or political involvement; 7.9.7. information that may tend to compromise the safety or security of the public or public systems; 7.9.8. content that violates a legal ownership interest of any other party. 7.10. Agencies/Departments choosing to allow posts from the public on County social network sites, shall prominently display, or provide a link to, the County’s eGovernment Comment Policy. 7.11. Agencies/Departments choosing to use public comments shall consult with County Counsel to develop agency‐ or department‐specific disclaimers to meet the County’s legal needs. County Counsel may also be consulted to determine whether to remove comments that violate this policy. 7.12. County Blogs shall be established with moderated controls, which at minimum require that blog post (comments) be approved prior to blog publishing. 7.12.1. Agencies/Departments that choose to use blogs shall designate a moderator whose responsibilities will include the review of any comments submitted as part of an online discussion. 7.12.2. Comments or posts that do not comply with the County’s eGovernment Comment Policy or Appropriateness of Content Policy shall not be approved for blog publishing. -138- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 9 of 14 Policy 8 User Behavior The same standards, principles and guidelines that apply to County of Orange employees in the performance of their assigned duties apply to employee social media technology use. 8.1. County workforce members authorized to use social media technology shall do so only within the scope defined by their respective agency/department per policy 4 of this document and in compliance with all County Workforce, eGovernment and IT policies, practices and use agreements. 8.2. It is strongly recommended that social media use be performed within the County’s established Social Media Guidelines. 8.3. Authorized social network spokespersons participating in personal social networking discussions related to County business matters shall indicate that viewpoints are personal and may not reflect County opinion. 8.4. Authorized County social media users shall complete social media security training. 8.5. Workforce members performing County social media work beyond normal work hours shall receive pre‐authorization from the agency/department. 8.6. Employees shall obey all laws, including but not limited to, the Hatch Act of 1939, when using social media. Policy 9 Records Management Agency/Department use of social media shall be documented and maintained in an easily accessible format that tracks account information and preserves items that may be considered a record subject to disclosure under the California’s Public Records Act or required to be retained pursuant to the Government Code. 9.1. Agencies/Departments are responsible for the creation, administration and deactivation of social media accounts. 9.1.1. Account password information shall only be shared with authorized staff that has been designated by the Department Head, or her/his designee, to fulfill the role of site account administrator. -139- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 10 of 14 9.1.2. Passwords shall conform to County complex password requirements when permissible. 9.1.3. Account password shall promptly be reset when an employee is removed as an account administrator. 9.2. Agencies/Departments shall maintain a record of social media sites created for County use, including, but may not be limited to: 9.2.1. A log file containing the name of the social media network, account id, password, registered email address, date established, authorizing representative and name of person who created account and agreed to the sites terms of use agreement and/or policy. 9.2.2. A record of the sites usage agreement at the time the site was created and any updated versions. 9.2.3. A list of authorized site content authors and editors. 9.3. Electronic information posted to a social media site by the County, or a member of the public if permitted, may be considered a record subject to California’s Public Record Act. 9.3.1. Any content maintained in a social media format that is related to County business, including a list of subscribers and County or public posted communication, may be a public record. Agencies/Departments shall have procedures in effect to preserve published social media content. 9.3.2. The Agency/Department maintaining the site is responsible for responding completely and accurately to any public records request for public records on social media. 9.3.3. Site content shall be maintained in accordance with its respective Records Retention Schedule and in accordance with County IT policies and procedures. If the content constitutes a public record, it must be disclosed to the public unless an exemption applies. -140- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 11 of 14 9.3.4. Posts deemed technically harmful or inappropriate per policy 7 shall be promptly documented, saved pursuant to IT policies and procedures regarding record retention and removed. 9.4. Agencies/Departments shall maintain a record of signed social media policy acknowledgement forms for each authorized user. Policy 10 Site Monitoring Agency/Department social media sites shall be monitored regularly and prompt corrective action shall be taken when an issue arises that places, or has potential to place, the County at risk. 10.1. Agency/Department social media site administrators shall review site activity and content daily for exploitation or misuse. 10.2. Agency/Departments that allow the public to post comments, links or material directly onto their social media sites shall have an established process, including technical capability outside of the County’s network, to verify that postings meet the rules established under policy 7 of this document. Posts deemed technically harmful or inappropriate shall be handled per procedure 9.3.4. Agencies/Departments choosing to use public comments shall consult with County Counsel to develop agency‐ or department‐specific disclaimers to meet the County’s legal needs. County Counsel may also be consulted to determine whether to remove comments that violate this policy. 10.3. Agencies/Departments shall be responsible for monitoring employee use of social media and social networking websites. 10.4. Perceived or known compromises to the County’s internal network shall be promptly reported to CEO IT’s Chief Security Officer. -141- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 12 of 14 VI. RELATED REFERENCES 1. County Approved Social Media Networks and Standards 2. County Social Media Participation Guidelines 3. County eGovernment Policies and Standards 4. County Internet and Data System Use Agreement 5. County Electronic Records Management Policy 6. County Legal Hold Policy 7. California Public Records Act 8. Agency/Department Public Information Policies and Procedures 9. Agency/Department Records Retention Policies and Schedules -142- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 13 of 14 VII. DEFINITIONS Social Media and Web 2.0 ‐ The U.S. Government defines social media and Web 2.0 as umbrella terms that define the various activities that integrate technology, social interaction, and content creation. Through social media, individuals or collaborations of individuals can create web content, organize content, edit or comment on content, combine content, and share content. Social media and Web 2.0 uses many technologies and forms, including RSS and other syndicated web feeds, blogs, wikis, photo–sharing, video–sharing, podcast, social bookmarking, mashups, widgets, virtual worlds, micro– blogs, and more. Not all forms of social media may be appropriate for use by County agencies and departments. Official County Email Account – Email account provided by an agency/department mail system or approved external mailbox that is used for official County business. Approved County Social Networking Site – Refers to social networks that the County Executive Office has assessed and approved for use by County Agencies and Departments. Moderated Blog – The practice of approving blog contributor content (often referred to as user post or comments) prior to the content being displayed to blog visitors. Agency/Department Designated Blog Moderator – A County of Orange workforce member assigned to monitor and manage the stream of user contributions and interactions with an online County blog. In general, the blog moderator’s responsibility is to promote the quality and effectiveness of the blog and to insure that blog content, including user post, is in compliance with County policy. Post ‐ A user submitted message that may include comments and/or one or more links to online information including but may not be limited to websites, video, images, documents, computer applications, etc. -143- CCoouunnttyy EExxeeccuuttiivvee OOffffiiccee Information Technology Policy and Procedure County Social Media Use Policy v1.0 Page 14 of 14 Revision History: Revision No. Revision Date Author Description v1.0 3/30/2010 CEO‐IT Document originated -144- ATTACHMENT 7 -145- -146- From:ddavis@teac.com To:PLANNING INFO Subject:Official Public Notice: Application No. PGSH-24-0002 Date:Tuesday, October 14, 2025 11:28:06 PM To whom it may concern: I received an Official Public Notice regarding application no. PGSH-24-0002 for a sober living house at 1601 Baker Street. The notice states that public comments must be submitted by 12:00 PM on the date of the meeting. Following are my comments: I implore the Planning Department not to allow a half way house in the middle of a prime, family, residential community at 1601 Baker Street. I own property at Baker and Royal Palm. There are many young and teenage children that walk that section of Baker to access the shopping on Harbor Blvd. None of us want to have a child violated. The property is listed as having 4 bedrooms and two bathrooms. The application is for 7 adults. This is too many adults in the facility which could lead to problems with the neighbors, parking problems, trash and other conditions caused by over crowding. There are areas of Costa Mesa that are more suited to sober living, sex offenders and halfway houses. This residential community is not so suited. Please do not allow this residential home to be overcrowded and endanger the neighborhood. Respectfully, Derek Davis PO Box 10343 Costa Mesa, CA 92627 NOTICE: This electronic mail message and its contents, including any attachments hereto (collectively, "this e-mail"), is hereby designated as "confidential and proprietary." This e-mail may be viewed and used only by the person to whom it has been sent and his/her employer solely for the express purpose for which it has been disclosed and only in accordance with any confidentiality or non-disclosure (or similar) agreement between TEAC Corporation or its affiliates and said employer, and may not be disclosed to any other person or entity. CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Report any ATTACHMENT 8 -147- suspicious activities to the Information Technology Department. -148- From:Ronn Waters To:PLANNING INFO Subject:Application PGSH-24-0002 Date:Thursday, October 9, 2025 4:06:22 PM Why would you put a Sober Living Home next door to a Group Home for Kids. That does not sound helpful nor safe. For either. CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Report any suspicious activities to the Information Technology Department. -149- From:Ronn Waters To:PLANNING INFO Subject:Application PGSH-24-0002 Date:Thursday, October 9, 2025 11:06:17 AM Public Notice Comment: The SUP would make a bad parking situation worse. There is already one Group Home on Baker street and their staff/interns take up a lot of the available street parking. Those of us who actually pay taxes here are not able to park in front of our homes. The sidewalks of the recovery homes on Royal Palm are littered with cigarette butts. We don't need that on Baker street. Ronn Waters CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Report any suspicious activities to the Information Technology Department. -150-