raw_content:
Narrative:
--(Continued from page LIC9099)-- Based on confidential statements and record review, the allegation concerning staff selling and distributing illegal drugs at the facility cannot be substantiated due to a lack of evidence. The findings are therefore determined Unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies cited per Short-Term Residential Therapeutic Program Interim Licensing Standards or California Code of Regulations, Title 22, at this time. Exit interview completed. A copy of this report and LIC811 was provided to the Facility Representative Exit interview conducted with Facility Representative. A copy of this report and appeal rights are left with Representative.

Investigation Findings:
13On June 9, 2023, at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a follow-up complaint inspection to deliver findings from the Department's investigation. LPA met with Facility Representative, Madison Pennnington Facility Manager to discuss the outcome. On July 19, 2022, Community Care Licensing Division (CCLD) received an allegation that staff (unidentified) are selling and distributing illegal drugs at the facility. The allegation was referred to CCLD Investigations Bureau, Investigator Douglas Real. On July 21, 2022, LPA Regina Martin conducted the initial complaint inspection, met with the facility Manager and reviewed records. The investigation further consists of confidential interviews of youth and related parties, as well as review of facility file history. Confidential statements and record review revealed a lack of evidence to prove the alleged as information obtained determined no witnesses or corroborating evidence to substantiate reported claim. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: KIDS TO KIDS- FAITH HOUSEFACILITY NUMBER: VISIT DATE: 06/09/2023

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


state: CA

facility_name: KIDS TO KIDS- FAITH HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on October 27th, 2021 at 11:00am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 4 of Staff and 4 of 6 youth files as identified on the LIC 811 confidential names dated October 27th, 2021, were reviewed. 3 of Staff and 2 of 6 youth were also interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to CEO/ Administrator David Yasutake.

report_type: Facility Evaluation

visit_type: Case Management

met_with: CEO/ Administrator David Yasutake


facility_name: KIDS TO KIDS- RESTORATION

summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2021, Licensing Program Analyst (LPA) Regina Martin conducted a Case - Management Incident inspection to deliver and discuss findings from the Department's Investigation on self- reported incident received July 21, 2020. LPA met with Facility Representatives, Shannon Walling, Facility Manager and Andrea Espinosa Senior Facility Manager and together discussed investigation details. On July 21, 2020, Community Care Licensing received an incident report from facility representatives reporting that Staff member #1 (S1) contributed marijuana to minors. The incident was referred and assigned to Investigations Bureau, Investigator, Dennis Douglas. The investigation revealed, according to gathered information from independent interviews and review of corresponding records including incident reports and reports from the Ventura County Police Department, S1 provided and smoked marijuana with several of the clients at the facility. The marijuana was provided by S1 to the clients in the form of a "wax pen" and a "pipe". Sources revealed the encounters would occur outside of the facility during "walks" or while S1 was in the facility vehicle with the clients. S1 admitted to Investigator Douglas that she provided and smoked marijuana with the minor clients. Confidential independent interviews with clients residing in the facility at the time, further corroborate claims as some residents admitted to smoking marijuana out of S1's "wax pen" with S1 on several occasions and S1's "pipe" on at least one occasion. Upon discovery of said incident, S1 was terminated from her position at the facility. Facility representatives notified all required parties and conducted an internal investigation pertaining to the incident. (Continued on pg. Lic809d) Corrections concerning facility policy and procedures pertaining to this incident were reviewed and updated as necessary. Based on gathered information there is corroborating evidence to support reports of S1 contributing marijuana to minors. S1's actions towards clients poses an immediate health, safety and personal rights risk to children placed in care. The facility is issued a citation in accordance with Health and Safety code HSC 1558 (a)(2) Conduct inimical. See page 809D for deficiency. Exit interview conducted; Appeal Rights issued. A copy of this report was emailed to Facility Representatives.

met_with: Shannon Walling, Facility Manager; Andrea Espinosa,Senior Manager


facility_name: KIDS TO KIDS - SERENITY HOUSE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On June 25, 2021 at 1:20pm Out of State Group Home Analyst Sarah Waklee called Kids to Kids Serenity House, Senior Manager to discuss the above allegation. Analyst Waklee made multiple attempts to contact the named youths Social Worker, all of which were unanswered and voicemails unreturned. The named youth is no longer at the facility, therefore Analyst Waklee was unable to interview the youth. Based on confidential interviews with staff, Analys Waklee determined that the allegation is unsubstantiated. An unsubstantiated finding means, although the allegation may have happened, the preponderance of evidence does not prove it. A copy of this report was provided to Kids to Kids Serenity House. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Sarah Waklee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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

report_type: Complaint Investigation

met_with: Andrea Espinosa, Senior Manager

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On July 2, 2021 at 3:45 pm Out of State Group Home Analyst Sarah Waklee called Kids to Kids Serenity House, Senior Manager to discuss the above allegation. Analyst Waklee made multiple attempts to contact the named youths Social Worker, all of which were unanswered and voicemails unreturned. The named youth is no longer at the facility, therefore Analyst Waklee was unable to interview the youth. Based on confidential interviews with staff, Analys Waklee determined that the allegation is unsubstantiated. An unsubstantiated finding means, although the allegation may have happened, the preponderance of evidence does not prove it. A copy of this report was provided to Kids to Kids Serenity House. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Sarah Waklee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
per California Code Regulations, Title 22, Division 6, Chapter 1, 80074(c) Transportation / Interim Licensing Standards 87074 (d)(e) Transportation on the attached LIC 9099D. A Type "A" citation for Immediate Health & Safety Hazard has been issued. Exit interview conducted. Copy of this Report and Appeal Rights emailed to Facility Representative. Exit interview conducted. Copy of Report and Appeal Rights also given to Facility Representative.

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

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

met_with: Manager Lina Severino

complaint_status: SUBSTANTIATED


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

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

met_with: Dan Bakst, Head of Service


raw_content:
Investigation Findings:
13On Friday January 14, 2022 at 4:45PM Licensing Program Analyst (LPA) Kathy Landry conducted a Tele-Inspection with representative listed above. There were no clients residing at this facility on this date and time. LPA Landry conducted an entrance interview and discussed the findings for this investigation. This investigation initially began 12/22/20 and since then more information was received. LPA Landry conducted confidential interviews with client(s), several staff and Department of Children and Family Services Social Worker. On or around December 20, 2020 tensions arose in this facility, an altercation occurred and child #1 assaulted child #2. As a result of the altercation child #1 was arrested and child #2 was hospitalized for injuries. Regarding all allegations listed above, all pertinent parties were not available for interviews, LPA Landry received conflicting statements thus far and is unable to determine if these allegations occurred. Based on information received at this time all allegations listed above are unsubstantiated. "Unsubstantiated" means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Copy of Report and Appeal Rights delivered to Representative via email. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Kathy Landry LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Dave Yasutake, Administrator


raw_content:
Narrative:
On 03/08/2021 at approximately 12:00pm, Client#1 (C1) and Client#2 (C2) informed facility staff they wanted to runway (AWOL) from the facility. Facility staff attempted to redirect C1 and C2 by offering to go on a walk, do activities, and added extra supervision. Around 4:50pm, C1 and C2 packed their belongings and walked out from the front door. Staff was able to obtain the vehicle plates, make and model of the vehicle that picked up C1 and C2. Facility contacted Ventura County Police Department to report missing person report. At 7:15pm Ventura County Police officer arrived at the facility to take the report. Interviews with facility and clients reported the facilities policies and procedures in what facility does when clients runway. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Neglect and Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On July 28, 2022, at 09:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Faith House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. On 04/30/2021, LPA Enrique Hernandez conducted a facility inspection and conducted interviews. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated June 28, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas determined that Neglect/Lack of Supervision allegation that facility staff is not preventing minors from running away (AWOL), may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 07/28/2022

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

met_with: Staff#1 (S1)


raw_content:
Narrative:
The investigation revealed C1 was first placed August 18, 2021 with a history of anxiety, depression and prior suicide ideation without a plan. Confidential interviews and review of records indicates C1 was planning to graduate from facility's program and high school. On November 12, 2021, C1 appeared to be in a good mood and was last seen alive approximately 15 to 20 minutes before being found unresponsive. On November 12, 2021 at approximately 1: PM, Staff member found C1's bedroom door barricaded with a dresser. The door was pushed open and C1 was found partially suspended by a black cable cord secured to dresser drawers. Resuscitative efforts were begun, 911 emergency was called, and C1 was transported to a hospital where C1 was subsequently pronounced dead. Witness statements obtained indicate C1 appeared to be in a positive mood on the morning of the incident and showed no obvious signs of distress, plans to harm self or plans to commit suicide. Ventura County Police Department responded to the incident and found there was no crime committed. Ventura County Medical Examiner Investigator determined no suspicions of foul play regarding the incident. Based on gathered information obtained, there is not enough evidence to prove C1's untimely passing resulted from questionable death, but rather by suicide by hanging self from a closet drawer in their room. The findings are deemed Unsubstantiated. There are no deficiencies cited per California Code of regulations at this time. Exit Interview conducted. A copy of this report, LIC811 and appeal rights are provided to Facility Representative.

Investigation Findings:
13On August 19, 2022 at 2: PM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection at KIDS TO KIDS-FAITH HOUSE to deliver findings concerning the above-mentioned allegation, regarding the KIDS TO KIDS - SERENITY HOUSE facility location. LPA Martin met with Facility Representatives to discuss the investigative outcome. The investigation was conducted by Investigator Tiffany Brunelli of the Community Care Licensing Division (CCLD) Investigations Bureau. On November 17, 2021, CCLD received a complaint allegation concerning questionable death of Client #1 (C1) who reportedly sustained death while in care (see LIC811, dated 8/19/2022). On November 19, 2022, Investigator Brunelli initiated the investigation, conducted an unannounced inspection at the Kids to Kids Faith House location, met with Facility Representative and issued a 10-Day Complaint Notification. Investigator Brunelli completed the investigation consisting of, confidential interviews with witnesses, clients/residents, staff members, Ventura County Medical Examiner Investigator, review of related incident report, review of client file history and recent timeline of events, as well as review of the Ventura County Police Department Incident Report. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 08/19/2022

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

met_with: Facility Representatives, Xiomara Lopez, Assistant Manager Danny Bakst, Head of Service


raw_content:
Narrative:
The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. LPA Rosas and AGPA Barnes-Woodard conducted interviews with clients and facility staff that provided information on how minors in placement receive therapy sessions, provide a supportive environment for minors and facility services. Staff and clients provided statements on how the facility has onsite therapist and clients are encouraged to attend therapy sessions. The facility had provisional Short Term Residential Therapeutic Program (STRTP) and was partner with Ventura County to provide mental health services. The facility provides the residents psychosocial and other alternative treatments such as Art, Equine Therapy, Individual Therapy, and community outings. The staff and clients describe the care and supervision of the facility. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On September 1, 2022, at 09:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Serenity House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted inspection and conducted interviews. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated September 1, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Personal Rights allegations that facility staff does not ensure that minors receive therapy sessions, provide a safe and supportive environment, and does not treat all minors the same. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 09/01/2022

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


facility_name: KINFOLKS HELPING HANDS INC

summary: Facility Evaluation

raw_content:
Narrative:
On September 4, 2025, at 10: AM, via Microsoft Teams, Community Care Licensing (CCL) and Systems of Care (SOC) conducted a Technical Assistance Call (TA) with the applicants of Kinfolks Helping Hands, Inc. The meeting was attended by Ansar Muhammad, Associate Governmental Program Analyst (AGPA), Marjana Jackson, Staff Services Manager I (SSM I), Cynthia Velasquez, Licensing Program Analyst (LPA), Dawn Segura, Licensing Program Manager (LPM), Demetri Roberts, Applicant, and Naja Roberts, Applicant. The purpose of the meeting was to discuss the Short Term Residential Therapeutic Program (STRTP) Application and Plan of Operation/Program Statement submitted to CCL on 03/28/2025. Applicants noted that the incorrect version of form LIC 9106 was initially submitted. Subsequently, applicants completed the correct version of the LIC 9106A form. During the call, the following topics were discussed: Application 1. Bacterial Analysis - Not Applicable. Applicants will not be using a private water source. Plan of Operation and Program Statement 2. Staff Plan - In addition to staff, applicants plan to utilize house parents who will incorporate prudent parenting standards to facilitate a home-like environment. 3. Population To Be Served • Facility will serve children 8 through 17 years of age; facility will not serve nonminor dependents • Children with Special Health Care Needs - Applicants will review ILS section 87001 and additional regulations to determine if children with special health care needs will be served. 4. Personal Rights - Applicants plan to utilize video surveillance outside of the facility. Applicants were provided the Provider Information Notice (PIN 24-09-CRP) that provides guidance on the use of video cameras in children's residential congregate care facilities. 5. Emergency Intervention Plan - Applicants indicated that CPI and Ukeru System will be utilized if other efforts have been exhausted. Applicants were provided information related to available resources provided by the state and county that can be used when outside intervention is needed. Applicants were advised to utilize 911 as a last resort. Applicants stated that required documents and revisions will be provided to CCL by 09/12/2025. A copy of this report was sent to Naja Roberts, Applicant, for signature. The signed report will be maintained in the facility file in the Riverside Regional Office.

visit_type: Prelicensing

met_with: TA Call - Teams


summary: Facility Evaluation

raw_content:
Narrative:
On March 5, 2026, Licensing Program Analyst (LPA) Cynthia Velasquez, and Licensing Program Manager (LPM) Abdoulaye Traore, met with the applicant Demetri Roberts to go over revision of the program statement and plan of operation. LPA and LPM advised applicant to correct and bring back the required documents.

met_with: Demitri Roberts, Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On May 12, 2026, Licensing Program Analyst (LPA) Cynthia Velasquez, and Licensing Program Manager (LPM) Abdoulaye Traore, met with the applicants Najah and Demetri Roberts, to discuss revisions submitted, and next steps in application process.

met_with: Najah and Demetri Roberts, Applicants


facility_name: KOINONIA HOMES FOR TEENS #5

raw_content:
Narrative:
Youth also made statements that staff disrespected her and she did not want to go back to the facility. The youth's whereabouts are unknown therefore no statement was obtained from youth. Staff stated having no knowledge of escalation prior to youth leaving nor did staff know youth was disrespected. Based on the information obtained the allegations, that minor was mistreated while in care and staff are not properly supervising the minor, are UNSUBSTANTIATED. Although the allegations may or may not have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights and the LIC811 were discussed and left with Bill Ryland.

Investigation Findings:
13On 6/28/21 at 9:17 am, Licensing Program Analyst (LPA) Robin Sullivan contacted Bill Ryland (S1), to deliver the finding for the allegation that minor was mistreated while in care and staff are not properly supervising a minor in care. LPA Marla Horne opened the initial investigation with the facility on 3/25/21 and received a client roster and a staff duty roster. LPA Robin Sullivan interviewed an Auburn Police Sergeant on 6/23/21, two facility employees and the Merced Probation Officer on 6/22/21. LPA Sullivan received one youth's Needs and Services Plan, Treatment plan, incident reports, and discharge summary from the facility and a police report from the Auburn police department. The investigation revealed that the youth has a history of leaving facilities without permission. The youth left the facility without permission on the evening of 3/13/21 after watching a movie. Staff contacted Law Enforcement (LE) to report the youth missing. LE located youth but youth refused to return to the facility. Youth was held in protective custody for safety until an agreement to return was hesitantly made. Youth made statements to LE that she wanted to be back in her hometown. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Robin Sullivan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: KOINONIA HOMES FOR TEENS #5FACILITY NUMBER: VISIT DATE: 06/28/2021

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

met_with: Bill Ryland, Director


raw_content:
Narrative:
Multiple professional staff confirmed that while having private conversations with the youth on the phone, staff from Koinonia #5 were presented and answered the professional staff's questions for the youth. Based on additional interviews, staff are supervising youth while youth make personal phone calls. It was confirmed that no youth had court order in place with or without restricted/monitored phone calls. Therefore, the preponderance of the evidence standard has been met and the above allegation is determined to be SUBSTANTIATED. The facility is cited on the attached 9099-D. An exit interview was conducted, a copy of the report, and appeal rights will be emailed to Facility Administrator. Based on the interviews with the youth and staff, they confirmed that the searches and bathroom privacy were appropriate, and none felt violated. Although youth stated that they were not provided condiments for food, there is inconsistency based on the interviews. Staff denied the allegation of inappropriately disciplining the youth and provided LPA a list of chores in the STRTP. In addition, the Program Statement was reviewed and confirmed their disciplinary policy. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations; therefore, the above allegations are unsubstantiated. Appeal Rights will be emailed to Facility Administrator.

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

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

met_with: Patti Ambriz, Facility Administrator


raw_content:
Narrative:
The information communicated regarding the agency's expectations for the staff while supervising clients was presented as general guidelines rather than a written policy. Furthermore, the placing county social worker provides the parameters for the visit supervision expectations. Because of the lack of overall corroboration regarding the allegations and facility policy, the allegations are determined to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report and appeals process were provided.

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

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

met_with: Administrator


raw_content:
Narrative:
LPA Lor reviewed Koinonia's Facebook page and the following were discovered: pictures of foster youth and pictures of certificates with foster youth's names were listed. Therefore, the preponderance of the evidence standard has been met and the above allegations are determined to be SUBSTANTIATED. The facility is cited on the attached 9099D. An exit interview was conducted with FFA Administrator. A copy of this report and the Appeal Rights will be emailed to the agency. Based on the interviews with C1, C2, C3, C4, C5, C7, C8, C9, S1, S2, S3, S5, and S6, it was confirmed that there are a variety of social interaction opportunities available to the youth. A majority of the youth confirmed that they enjoyed the activities and had no complaints about them. Only 1 out of the 9 youth stated that a self interest opportunity was denied to the youth. Based on the interviews with C1, C3, C4, C5, C7, C8, and C9, they did not have any concerns regarding their education at Koinonia. Only 2 out of the 9 youth did not provide a direct answer. S2, S3, and S5 confirmed that there are a variety of educational services provided to the youth such as therapy, IEP, college and career counseling, tutoring, and after school programs. Based on the interviews with S1, S6, S8, and S9 they confirmed that prior to the youth's placement, an agreement is made between the child's team to place the youth at the Koinonia School. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations; therefore, the above allegations are unsubstantiated. No deficiencies were cited. An exit interview was conducted with FFA Administrator. A copy of this report and the Appeal Rights will be emailed to the agency.

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

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

met_with: Patricia Ambriz, FFA Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/9/22, Licensing Program Analyst (LPA) Stephanie Lor, LPA Tana Kinder, and Program Manager Rosa Rodriguez met with Director to discuss concerns for Koinonia House #5 and #3. The list of concerns include: -Unreasonable consequences for the youth -Staff used of profanity at the facility -Staff usage of personal phone during supervised visit -Denial of phone call to youth to make confidential phone call to the Foster Care Ombudsman. -Youth not allowed to have private phone call conversations with their Social Workers and other professional staff. -Broken washer appliance. Director reported that the staff have been trained on Foster Youth Rights and explained the phone policy for staff and youth. Director will email LPA Lor a revised program statement of the policy. Director will address the concerns with the facility and will follow up with LPA Lor on 2/11/22.


facility_name: KOINONIA HOUSE #1

raw_content:
Narrative:
During the course of the investigation, LPA Diaz found out that this was the first time both parties were dealing with a client transitioning from one STRTP to another STRTP. Based on interviews conducted from facility staff, and other witnesses, it was confirmed that this was the first time to have a client transfer to a different STRTP and it was a unique situation for both parties. LPA Diaz also, found documentation on staff training records, regarding confidentially. In addition, other witnesses, also confirmed that this was the first time they have encountered this type of issue with this facility, and generally this facility is good, and they never had issues in the past. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above allegation occurred; therefore, the above allegation is unsubstantiated. Appeal Rights were provided to the above facility. No deficiencies were cited. Exit interview was conducted with Lisa Wilcox, Facility Administrator Assistant, and Troy Sheridan, Facility Administrator.A copy of the report was emailed to Bill Rylan, Administrator.

Investigation Findings:
13On February 17, 2022 at 10:30am Licensing Program Analyst (LPA), Yuvi Diaz conducted a follow-up complaint investigation and met with Lisa Wilcox, Facility Administrator Assistant, and Troy Sheridan, Facility Administrator. The purpose of the inspection was to deliver findings for the above complaint allegation. Prior to delivering complaint findings LPA Diaz reviewed the client's file at the facility. LPA Diaz conducted an inspection of the facility, and no deficiencies were cited at that time. LPA Diaz conducted 7 confidential interviews between 11/22/2021-02/15/2022. LPA obtained and reviewed the following documents: Progress Notes, Client Roaster, Agency Group Home Agreement, Medical Consent Form, Needs and Service Plan, Authorization for Release of Information, Face Sheet, Medical Consent Form for Treatment of a Minor, Notice of Privacy Practices-Acknowledgement, Media Release Form, Notification from of EPSDT was provided, County Approved Contacted Sheet, County Letter for Placement. Koinonia letter to Placer County Unified School District, Training Records of Confidentiality. Report continues on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Yuvicela Diaz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: KOINONIA HOUSE #1FACILITY NUMBER: VISIT DATE: 02/17/2022

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


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
facility to request for the rest of C1's belongings. LPA also conducted interviews with witnesses that were consistent in their facts establishing the event had occurred. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards, Title 22, 87072 (6)(C), Personal Rights Chapter 6, are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator. A copy of this report and the Appeal Rights will be emailed to the agency.

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

met_with: Dareal Morales, Facility Administrator


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
there were no incidents of sexual or physical assault during that time. C2 reported that there were arguments in the home, but never heard or saw clients exposing themselves to another client. In addition, staff reported that they were not aware of the incident that happened involving the youth. IB Investigator Borton was unable to interview other youth present at the time of the incident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator Assistant. A copy of this report and the Appeal Rights were provided to the agency.

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

met_with: Marsh Hesch, FFA


raw_content:
Narrative:
Client interviews also reported that staff are supervising the clients in the home and checking in with them. Interviews from witnesses reported not having major concerns for the facility. It was reported that the facility would take care of the issue if a client damaged property in the neighborhood. Lastly, LPA was unable to interview past clients due unknown whereabout and disconnected phone number. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator . A copy of this report was provided to the agency.

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

met_with: Eddie Sanchez, Administrator


raw_content:
Narrative:
Furthermore, in reviewing the staff roster LPA observed there to be adequate staff scheduled for the day of the incident. Although the allegation may have happened or is valid there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Eddy Sanchez, Facility Administrator. Appeal Rights were discussed and a copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On April 8, 2024, at approximately 9: A.M., Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived unannounced at Koinonia House #1 and met with Eddy Sanchez, Facility Administrator for the purpose of delivering findings for the above allegation. During the investigation, LPA reviewed the agency's file at the licensing office, including complaint history, criminal background check, incident reports, and facility personnel summary. LPA reviewed Case Notes, Needs and Services Plans, rosters for both Staff and Youths in the Facility. LPA conducted 8 confidential interviews. Based on interviews conducted LPA was not able to substantiate the above allegation because LPA received inconsistent statements during the investigation process. Even though the incident took place, the staff was present and tried to prevent the physical altercation between minors while in care by talking to them. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KOINONIA HOUSE #1FACILITY NUMBER: VISIT DATE: 04/08/2024

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

met_with: Eddy Sanchez, Facility Administrator


raw_content:
Narrative:
S1 however, responded to the youth via Instagram message to only lay down a firm boundary and nothing inappropriate occurred. Licensee responded by transferring S1 out of the facility to protect S1 from the allegations and comments that were being made by the youths in care. Also, no probation officers held any concerns as to the safety of the youths in care and would like to place more youths in the facility. Lastly, LPA was unable to speak with C1 regarding the allegation. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did occur therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and Appeal Rights were discussed with Canaan Sampson, Facilities Supervisor. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On January 10, 2025, Licensing Program Analyst (LPA) Sara Luman-Gonzalez conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Canaan Sampson, Facilities Supervisor and was granted entry. During the investigation, LPA conducted the 10-day inspection of the facility on September 3, 2024. LPA obtained Client Facesheets, Staff Roster, Schedules, Case Notes, Needs and Services Plan, and Staff Files. 15 confidential interviews were conducted between September 2024 and January 2025 by LPA Luman-Gonzalez. Based on Interviews conducted and records review throughout the investigations process, LPA was provided inconsistent statements as to what occurred. 7 out of 15 interviews stated that nothing occurred. C1 was no longer placed at the facility and their bed had been closed out when they reached out to S1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KOINONIA HOUSE #1FACILITY NUMBER: VISIT DATE: 01/10/2025

met_with: Canaan Sampson, Facilities Supervisor


raw_content:
Narrative:
C2 was observed to have extreme behaviors, including acting out in a harassing manner towards other youths in the facility as well as staff. Staff notated that they did reach out to the management regarding assistance with C2 and their supervision needs as well as concerns with C2's sexually aggressive behaviors towards another youth placed in the facility. As issues were arising, the facility was unable to address these in a timely fashion which allowed the client to continue the negative behaviors towards staff and other youth. Also, staff suspected that a wax pen was sneaked into the facility by client in care. Staff witnessed C2 showing signs of being high and random puffs of smoke exiting the bathroom area while youths utilized the restroom. Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Interim Licensing Standards (LIS) are being cited on the attached LIC 9099D. Exit interview conducted, and Appeal Rights were discussed with Linda Wagner, Facility Administrator. A copy of this report and Appeal Rights were left at the facility. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did occur therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and Appeal Rights were discussed with Linda Wagner, Facility Administrator. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On 7/16/ Licensing Program Analyst (LPA) Sara Luman-Gonzalez conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Linda Wagner, Facility Administrator and was granted entry. During the investigation, LPA conducted the 10-day inspection of the facility on 4/16/25. LPA obtained Staff to Staff Notes from 1st of March, STRTP Notes since 1st of March, Needs and Services Plans, Client Face sheets, Staff Schedule for both March and April, and Contact information, as well as Admissions Documentation for one youth. 17 confidential interviews were conducted between April 2025 to June 2025 by LPA Luman-Gonzalez. Based on interviews conducted during the investigation process, the above allegations are substantiated. LPA confirmed that Staff were unable to prevent inappropriate interactions between minors at the facility and Staff did not prevent minor from smoking inside the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KOINONIA HOUSE #1FACILITY NUMBER: VISIT DATE: 07/16/2025

met_with: Linda Wagner, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Marla Horne and Mary Shelton made an unannounced annual inspection on 10-4-21 at 9: A.M. LPAs met with Facility Administrator Kamron Batston and Program Director Bill Ryland. LPAs observed all required postings posted. LPAs observed and tested 6 smoke detectors and 2 carbon monoxide detectors. LPAs observed 3 bedrooms which contained the appropriate bedding and furniture. LPAs observed new carpet in the bedrooms. The water in bathroom sinks tested at the required temperature. LPAs observed the kitchen refrigerator, freezer and pantry to be filled with perishable and non- perishable food items. LPAs observed an adequate supply of utensils and dishes. LPAs observed the outdoor area to be clear of clutter and debris. The facility vans contained first aid kits, current registration and vehicle logs. The brake lights and turn signals are in working order. LPAs observed medications and sharps to be locked. Fire extinguishers were clearly marked with a service date of August 2021. LPAs reviewed staff and youth files, all required documents were observed in the files. LPAs interviewed staff and youth. No citations issued during this inspection. A copy of this report was left with Kamron Batstone.

visit_type: Annual

met_with: Kamron Batstone, Facility Administrator and Bill Ryland Program Director


facility_name: KOINONIA HOUSE #2

raw_content:
Narrative:
Staff used an inappropriate form of discipline. Based on confidential interviews, youth are completing excessive amount of Therapeutic Assignment (TA). Some interviews reported that the 16/20 exercises could be doubled up, which causes the youth to be very tired out. It was noted in the facility program statement that 16/20s are a form of discipline in the program. Staff enforced an unreasonable dress code for minors Based on confidential interviews. there were conflicting statements about the dress code. Some interviews reported that the dress code is for the safety of the youth, however, other interviews were reported that the dress code was too strict. The dress code policy was noted in the facility program statement of what is allowed and what is not allowed. Staff forcing minors to be drug tested. Based on all the confidential interviews, it was reported that youth are required to take random drug tests after awols, home passes, or any outings that were without a staff supervision. It was noted on the program statement that random drug test could be required when appropriate. Staff not allowing minors to have private phone calls. Based on the confidential interviews, there were conflicting statements on private phone calls. Some interviews reported that private phone calls are allowed, while other interviews stated that staff are supervising during phone calls. Staff require minors to complete an excessive amount of chores. Based on the confidential interviews, there were conflicting statements on youth are completing excessive amount of chores. Some interviews reported that the chores are too much while others reported that they did not have an issue with the chores in the home. It was noted on the facility program statement on chores provided in the home. Minors are required to cook meals. Based on the confidential interviews, there were conflicting statements on youth requiring to cook meals. Some interviews reported that youth are not required to cook meals, but can switch chores if the youth did not want to cook. Some interviews reported that cook is part of the chores and youth can get consequences (Cont on 3rd page) if chores were not completed. It was noted in the facility program statement that cooking is part of the chores in the home. Facility program statement is unreasonable. The program statement is currently being edited. The program statement has been updated to ensure that it allies with the the updated version of Title STRTP Regulations. Facility withheld minor's personal item. Based on the confidential interviews, there were conflicting statements on withheld of personal items. Some interviews reported that the youth are given their personal items upon request, while some interviews reported that youth cannot have access to their personal items. Staff force minors to attend religious services Based on confidential interviews, there were conflicting statements on force of attending religious services. Only 1 out of the 4 clients, reported that youth have to participate in the living room while completing work assignments. It was reported that the services were optional and youth are not forced to participate. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with the Administrator Assistant. A copy of this report and the Appeal Rights will be emailed to the agency.

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

met_with: Jasmine Brown, FFA Admin Assistant


raw_content:
Narrative:
Because general protocol was exercised and it cannot be determined if closer supervision would have prevented the AWOL and it was not verbally communicated or confirmed that sexual activity occurred during the AWOL the allegation is determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report and appeals process were provided.

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

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


raw_content:
Narrative:
The Assigned Probation Officer limited the use of telephones for the safety of the occupants inside the home and for public safety. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report was provided to Administrator, Jazmyn Brown.

Investigation Findings:
13On January 22, 2024 at approximately 12: PM Licensing Program Analyst (LPA) Farhaan Sarangi conducted a complaint investigation inspection at Koinonia House #2 and met with Administrator, Jazmyn Brown for the purpose of delivering findings. During the investigation, LPA Sarangi reviewed the complaint history, criminal background check, incident reports and facility personnel report summary. LPA Sarangi also reviewed facility files and client files. LPA Sarangi conducted interviews with staff and children in placement. In addition, LPA Sarangi conducted a collateral interview with a Supervising Deputy Probation Officer and the Assigned Probation Officer from Sacramento County Probation Department. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, during collateral interviews with the Sacramento County Probation Department, LPA learned that the client was presenting a safety concern for the children and staff in placement by communicating with an unknown individual via telephone. (Report continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Farhaan Sarangi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KOINONIA HOUSE #2FACILITY NUMBER: VISIT DATE: 01/22/2024

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

met_with: Administrator, Jazmyn Brown


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
All parties involved confirmed that a staff member made the clients feel disrespected and uncomfortable when a staff member wore inappropriate clothing at the facility and on one occasion lifted their own shirt, exposing their undergarments to the clients in care. It was also confirmed that the same staff member made inappropriate comments to one of the clients which made the client felt extremely uncomfortable and called their DPO. Per Law Enforcement Officers, the comments made by the staff member could be considered a form of grooming. In addition, other witness has also observed the staff member made comments about the client's appearances, weights, and food choices which made clients uncomfortable as well. Lastly, the facility has placed the staff in question in a 90- day trial, staff was moved to another facility, and was written up due to these allegations. Based on LPA's observations and interviews which were conducted and record reviews, the Preponderance of evidence standard has been met; therefore, the above allegation(s) are found to be SUBSTANTIATED. Interim Licensing Standards, Article 06, 87072 (c)(15)(16)- Personal Rights are being cited on the attached LIC 9099D. An exit interview was conducted, and Appeal Rights were discussed with Jazmyn Brown, Acting Facility Administrator. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On June 10, 2024, Licensing Program Analyst (LPA) Sara Luman-Gonzalez conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Jazmyn Brown, Acting Facility Administrator and was granted entry. During the investigation, LPA conducted the 10-day inspection of the facility on 5.6.2024, no deficiencies were cited. LPA obtained Staff Roster with Contact Information, Face Sheets, Case Notes from March 2024 to May 2024, Previous Incident Reports from March 2024 to May 2024, Needs and Services Plans, Paperwork from staff meeting held due to the allegation, Staff Training, Staff Schedules for March, and April 2024. 9 confidential interviews were conducted between May 2024 and June 2024 by LPA Luman-Gonzalez. Based on confidential interviews conducted during the investigation process, 9 out of 9 interviews corroborated that the allegations did occur. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KOINONIA HOUSE #2FACILITY NUMBER: VISIT DATE: 07/10/2024

met_with: Jazmyn Brown, Acting Facility Adminsitrator


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
out of the 9 interviews conducted confirmed a client was touched during a movie night on November 9, 2024, but it was also confirmed that staff were supervising the clients during movie night. One of the clients touched another client in care around the waist, hip, and thigh. Staff members were seated by the desk area overlooking the living room where the movie night was taking place. The incident happened so quickly that staff were not able to prevent the interaction between the clients in care. Staff members did not witness the incident taking place but it was confirmed and reported by other clients in care. During the investigation LPA Turner was informed one of the clients in care has been having inappropriate conversations and a lack of boundaries between other clients and staff. LPA Turner was informed that other clients keep their distance from this client. LPA Turner was notified by staff that the clients in care were separated and placed in different bedrooms. One of the clients in care is no longer able to have roommates due to their behaviors. Therapy and therapeutic assignments are taking place to encourage healthy boundaries between staff and clients in care, and to aid in navigating potentially harmful emotions and actions. Even though the incident took place, there was no lack of supervision during the incident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is UNSUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On February 20, 2025 at approximately 2: PM, Licensing Program Analyst (LPA) Zaria Turner made an unannounced visit to deliver findings to the above facility and met with Facility Administrator, Jazmyn Brown. Prior to the meeting LPA Turner initiated the complaint investigation on November 21, 2024. No deficiencies were cited during that inspection. LPA Turner requested the following documents: SIRs, needs and services plan, and IBSP for one client in care. LPA Turner conducted 9 interviews between November 21, 2024 and February 12, 2025. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegation cannot be substantiated because there were consistent statements throughout the investigation process. Report continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Zaria Turner LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KOINONIA HOUSE #2FACILITY NUMBER: VISIT DATE: 02/20/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

met_with: Jazmyn Brown, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Marla Horne and Cindy Johnson made an unannounced annual/required inspection of the facility on 10-26-21 at 9: AM. LPA's met with facility administrator Jordan Barbour and conducted an inspection of the inside and outside of the facility. LPA's observed required postings of facility license, foster youth rights, emergency evacuation plan as well as evacuation maps. LPAs observed operable smoke/carbon monoxide detectors and fire extinguishers. LPAs observed the kitchen refrigerator, freezer and pantry to have adequate supply of perishable and non-perishable food items. LPAs observed the bathrooms to have warm running water which is required. Bedrooms were observed to have required bedding and furniture. LPAs observed an adequate supply of bedding and linen. The outdoor area was clear of debris. The facility van was observed to have operable brake lights, headlights, turn signals and working seat belts. LPAs observed medications, sharps and cleaning supplies/chemicals to be in a locked cabinet. LPAs reviewed staff and youth files and all required documents were observed in the files. No citations issued during this inspection. An exit interview was conducted with Jordan Barbour. *

met_with: Jordan Barbour, Facility Administrator & Bill Ryland, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 11/14/22, Licensing Program Analyst (LPA) Stephanie Lor met with the Facility Administrator for the purpose of an annual inspection. The required posters were posted in the front. The kitchen has a table, chairs, freezer, and a menu was posted. LPA Lor observed the facility has enough perishable and non-perishable food. LPA Lor observed the medications, chemicals, knives were inaccessible to clients in care. A trash bin with a lid is located in the kitchen. The living room had 2 couches, tv and storage for games. There was a library and extra living room space for youth and visitors. The laundry and washer appliances were located in the hallway. Smoke detectors, carbon monoxide detectors and the fire extinguishers are in compliance. The first aid kit had all required items. There is adequate bedding, appropriate beds and ample storage for all clients in care. All bathrooms were tested and working. The water temperature was tested at 105'. LPA observed a fence around the facility pool. The pool was observed to be clean and blue in color. There was an extra house in the backyard for counseling and visits. The house and grounds were clean and sanitary. The facility vehicle was observed to be in good repair. LPA reviewed 5 staff and 2 youth files. LPA interviewed 2 staff. No clients were available to interview during this inspection. This report was discussed with the Facility Administrator and a copy will be emailed to the facility.

met_with: Ashley Young, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 11/21/22, Licensing Program Analyst (LPA) Stephanie Lor conducted a case management follow up regarding the phone policy that was brought up during 3 client interviews. 2 out of the 3 clients stated that staff listen to their phone calls. FFA explained the phone policy to LPA. It was confirmed that clients are allowed confidential phone calls. This case management investigation is closed.

met_with: Jazmine Brown, FFA Administrator


facility_name: KOINONIA HOUSE #3

raw_content:
Narrative:
Although a new appliance was replaced on 2/11/22, youth was without laundry service during the week that the washer was broken. Therefore, the preponderance of the evidence standard has been met and the above allegation is determined to be SUBSTANTIATED. The facility is cited on the attached 9099D. An exit interview was conducted with Facility Administrator. A copy of this report and the Appeal Rights will be emailed to the agency. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations; therefore, the above allegations are unsubstantiated. No deficiencies were cited. An exit interview was conducted with Facility Administrator. A copy of this report and the Appeal Rights will be emailed to the agency.

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

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

met_with: Troy Sheridan, Facility Administrator


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator. A copy of this report and appeal rights were left with the facility.

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

met_with: Canaan Sampson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts Marla Horne and Mary Shelton conducted an unannounced annual inspection of the facility on 9-30-21 at 9: AM. LPAs met with Bill Ryland, Program Director and Troy Sheridan, Facility Administrator. LPAs inspected the facility inside and outside. The facility has three bedrooms and currently has four residents in placement. LPAs observed the bathrooms to have running water at the required temperature. LPAs observed an adequate supply of perishable and non-perishable food items in the kitchen pantry, refrigerators and freezers. Items were labeled in the kitchen cabinets and in the pantry. Knives were locked in a kitchen drawer and medications were in a lock box in a locked cabinet in the staff area. LPAs observed two fire extinguishers and four operable smoke/carbon monoxide detectors. LPAs observed hand sanitizer, masks and COVID-19 posters at the facility entrance. Cleaning supplies were locked in a front hallway closet. LPA's reviewed staff and client files, all required documents were observed in the files. The facility has a swimming pool with a fence and self latching gate. The facility van seats nine and all seat belts are in working order. A first aid kit is located on the driver side of the van. Staff and clients were interviewed. No citations issued during this inspection. An exit interview was conducted with Troy Sheridan.

met_with: Bill Ryland, Program Director & Troy Sheridan , Facility Admiinistrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/9/22, Licensing Program Analyst (LPA) Stephanie Lor, LPA Tana Kinder, and Program Manager Rosa Rodriguez met with Director to discuss concerns for Koinonia House #5 and #3. The list of concerns include: -Unreasonable consequences for the youth -Staff used of profanity at the facility -Staff usage of personal phone during supervised visit -Denial of phone call to youth to make confidential phone call to the Foster Care Ombudsman. -Youth not allowed to have private phone call conversations with their Social Workers and other professional staff. -Broken washer appliance. Director reported that the staff have been trained on Foster Youth Rights and explained the phone policy for staff and youth. Director will email LPA Lor a revised program statement of the policy. Director will address the concerns with the facility and will follow up with LPA Lor on 2/11/22.

met_with: Bill Ryland, Director


summary: Facility Evaluation

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Narrative:
On 3/30/21 at 10:30am, Licensing Program Analyst (LPA), Stephanie Lor conducted a case management interview over the phone regarding personal rights. LPA conducted an interview with the Facility Administrator Assistant. The list of concerns include: -Youth have no privacy in the bedroom -Youth have no access to personal gifts/snacks Staff explained the protocols for when a youth can have privacy in the bedroom, this include when a youth is changing or asking for personal space. Staff explained that youth are allow to have access to their personal gifts/snacks. However, due to another youth in the home who has severe allergic reaction to certain food, staff manages when to provide personal snacks to youth in the home. This case management investigation is closed and no deficiency was cited. An exit interview was conducted with the Facility Administrator Assistant and a copy of this report will be emailed to the facility.

met_with: Marsh Hesh, Facility Administrator Assistant


summary: Facility Evaluation

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Narrative:
On 5/10/22 at 2:35pm, Licensing Program Analyst (LPA) Stephanie Lor made an unannounced visit to conduct a case management regarding incidents that were revealed to LPA during a complaint interview. A staff from House 3 informed LPA that House 3 has moved to House 1. This report is created to document this inspection; further investigation is needed.


facility_name: KOINONIA HOUSE #4

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Marla Horne and Cindy Johnson made an unannounced annual/required inspection of the facility on 10-12-21 at 9: AM. LPA's met with facility administrator Jordan Barbour and conducted an inspection of the inside and outside of the facility. LPA's observed required postings of facility license, foster youth rights,emergency evacuation plan as well as evacuation maps. LPAs observed operable smoke/carbon monoxide detectors and fire extinguishers. LPAs observed the kitchen refrigerator, freezer and pantry to have adequate supply of perishable and non-perishable food items. LPAs observed the bathrooms to have warm running water which is required. Bedrooms were observed to have required bedding and furniture. LPAs observed an adequate supply of bedding and linen. The outdoor area was clear of debris. The facility van was observed to have operable brake lights, headlights, turn signals and working seat belts. LPAs observed medications, sharps and cleaning supplies/chemicals to be in a locked cabinet. LPAs reviewed staff and youth files and all required documents were observed in the files. No citations issued during this inspection. An exit interview was conducted with Jordan Barbour.

met_with: Jordan Barbour, Facility Administrator


summary: Facility Evaluation

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Narrative:
On 12.4.24 at 10:00 am LPA Baca met with Facility Administrator Canaan Sampson, Compliance manager Laura Richardson, Program manager Sara Busse. LPA signed the component 2 form and verified photo Id's of all in attendance. LPA discussed next steps and calendared a time for the revisions to be submitted which is December 6, 2024 via Email. Provider will submit the sections highlighted for quicker review. Provider submitted an exemption for the stream in the back of the property that was dated 2015. the provider has a stream in the back of the property that needs to be accessible to the city when needed. The provider will not have young placement's and already has sensors on all windows and doors. the stream is 7 inches deep. LPA verified Administrators certificate. Provider asked for a time frame. LPA stated that there s a possibility that we can license the facility by the end of December, however that depends on when the revisions are received and when the LPA can schedule for the Pre licensing. Fire clearance-Completed Component 2 signed off Completed Component 2 face to face meeting Completed Verification of ID's Completed Credit check - Completed AARS- Completed First review-Completed Tech call with provider and SOC- Completed Fingerprints-Completed

met_with: Canaan Sampson, Facility Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Maie Soliman Licensing Program Manager (LPM) Dara Campos conducted an announced Pre-licensing inspection on 4/23/2025 at 10: AM at the above location, as required for the SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP) license. LPA and LPM met with Canaan Sampson, Facility Administrator Supervisor, Sara Busse, Program Director, Alyssa Miller, Office Manager, Aimee MarieL. Zapata, Clinical Facility Administrator. During the pre-licensing visit, LPA and LPM conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility has a canal that runs through the front and back yard. LPA Soliman observed the facility is a one story house. LPA observed three bedrooms and one staff office equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is requesting to be licensed for six youths ranging in age from 13 to 20 years old. LPA Soliman observed a medication Lock box in the staff office, which was empty, but locked, and accessible only to designated staff. The kitchen area was equipped with an adequate amount of utensils, dining supplies, and cups for clients. No food was observed as there are no clients, and no pending placement at this time. Facility will verify required food on hand at time of client placement. LPA observed a staff office space that is locked and inaccessible to clients, it will be utilized as the staff office for storing inaccessible medications and chemicals, in addition to any other item required to be inaccessible to clients. The staff office has a small fridge that will be dedicated to medications if needed. The facility has an attached garage space which houses a fridge and cabinets for extra food storage which is inaccessible to the clients at all times. LPAs observed a wood burner fireplace in the living room with a metal barrier. continued on 809_C page The smoke detectors and carbon monoxide detectors were tested. LPA obtained a copy of the fire clearance dated on 9/23/2024. A fully equipped first aid kit was reviewed and is placed in the staff office. The Foster Youth Bill of Rights was posted in a conspicuous location. There are 2 bathrooms in the facility that are accessible to clients use. The water temperature was tested and found to be not exceeding 120 degrees F. The facility is ready for license as SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP) effective today 4/23/2025. An exit interview waw conducted and a copy of this report was left with Canaan Sampson, Facility Administrator Supervisor.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Maie Soliman made an unannounced annual inspection on 3/6/2026 at 10:30 am. During the inspection LPA met with Stephanie Luke, Utilization Manager and Daryl Morales, Training Coordinator who assisted with the inspection. LPA Soliman conducted a walk-through of the facility, both inside and outside. There is a canal located in the backyard, for which the facility has an approved waiver. The facility has not had any placement since it was licensed. Number of staff interviewed __one___. LPA observed _three__bedrooms, __three_bathrooms, __one office__ LPA Soliman inspected and/or reviewed the following: I.Physical Plant Posting of license_X__ Personal Rights___X__ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F __X___ Freezer Temperature at or below 0 degrees___X__ Nonperishable Foods one week and fresh perishable foods two days minimum_N/A____ Menu present and posted__N/A____ Working telephone ___X____Carbon monoxide detectors _____X_____Smoke Detector __X___ First Aid Kit fully stocked__X__ Common Room available__X___ Dining area (enough seating, furniture good condition, not broke or damaged) ___X___ Medication centrally stored, locked/inaccessible __N/A___ Office (locked and privacy) ___X____ Hot Water between 105-120-degree F (Properly labeled if over 125 degree F__X____ Fire Extinguisher (note inspection date) __August 2025______Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature ___X____ Soap and Paper towels ___X___ Laundry Facilities(available) ___X__ Bedrooms-required linen and furnishings __X____ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts___N/A__ Facility free of vermin __X___ Locked Facilities (open locked storage area/building/sheds) ___X___Bedroom (required bedding/furniture, furniture in good repair) __X__ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed___X__ III. Disaster Preparedness Disaster and mass casualty plan updated and available___X_____ Quarterly Drills conducted and documented___N/A____ Disaster preparedness supplies verified ___N/A_____ LPA Soliman has not reviewed any client or staff files since the facility has not had any placement since it was lincensed. An exit in terview was conducted with Daryl Morales, Training Coordinator and a copy of this report was left with him.

met_with: Daryl Morales, Training Coordinator


facility_name: LA CHEIM STRTP

raw_content:
Narrative:
Appeal Rights were provided and discussed with the facility, and deficiencies were cited. Exit interview conducted and a copy of the report was left

Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the facility and met with Adminstrator, Sonam Prasad. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on an incident report from January 16, 2020, and interviews, Child #1 (C1) and Child # 2 (C2) (see Confidential Names form (LIC 811) dated {June 16, 2021}) got in a physical altercation, which resulted in (C1's) nose and head bleeding and client falling down the stairs and hitting his head on the wall.. Also, staff would watch clients fight for a short time before intervening. Based on documentation, police reports, and interviews, facility staff did not prevent youths from engaging in physical altercations. Based on the information obtained, there is a preponderance of the evidence. Therefore, the above allegation is substantiated. [Please cont. to LIC 9099.] SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: LA CHEIM STRTPFACILITY NUMBER: VISIT DATE: 06/16/2021

met_with: Administrator, Sonam Prasad.


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

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

met_with: Administrator Sonam Prasad


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The hired Head of Service does not have a master's degree nor any of the listed licenses. Further, the hired Head of Service has identified themself by multiple titles, including "Residential Director" in their email signature, which is not a listed job title in the approved POO. The preponderance of evidence standard has been met, and therefore the allegation "Head of Service not qualified" is found to be substantiated. Lastly, per applicable licensing requirements and the POO, the facility manager shall have either a bachelor's degree or two years of experience working with the population to be served or equivalent. When hired in October 2022, the facility manager had five months of experience as a direct care staff at the facility. The facility manager had multiple years of experience working with populations outside of the age range and care needs / behavioral backgrounds of the facility population. The preponderance of evidence standard has been met, and therefore the allegation "Facility Manager not qualified" is found to be substantiated. LPA is issuing one citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights, one citation of STRTP ILS Section Personnel Requirements, and one citation of STRTP ILS Section Plan of Operation. See attached deficiency pages. An exit interview was conducted, appeal rights were discussed and provided, and a copy of this report was provided to Administrator Sonam Prasad, whose signature on this form confirms receipt.

Investigation Findings:
13On 2/17/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit to deliver findings. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. The investigation consisted of confidential interviews with staff, residents, and witnesses and review of relevant facility records. Based on LPA's investigation, there have been multiple observations among staff and residents of inappropriateness from staff member(s), including wearing inappropriate clothing, inappropriate interactions with clients, and bias/favoritism. The preponderance of evidence standard has been met, and therefore the allegation "Staff being inappropriate with clients" is found to be substantiated. Additionally, based on LPA's investigation, both the Head of Service and Facility Manager are not qualified. The Head of Service may be filling the role as listed in the facility plan of operation (POO), based on review of applicable requirements and the POO, of the Social Worker/Clinical Coordinator or the Program Director. The former requires a master's degree and the latter a LSCW, MFT, or LPCC license. [] SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LA CHEIM STRTPFACILITY NUMBER: VISIT DATE: 02/17/2023


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on confidential interviews, the food supply was less than the required amount to meet the needs of the residents in care, including an empty refrigerator in the kitchen. Additionally, at least one resident has purchased their own food and keeps their own food supply in their room and has done so after requesting staff purchase preferred foods and those foods not being obtained and/or prepared. LPA observed the facility to require cleaning and multiple repairs. Outside, LPA observed trash and contraband in the side yard, including an empty water jug, two empty cigarette packs, and one lighter with lighter fluid. LPA removed the cigarette packs and lighter and handed to Administrator for disposal. LPA observed a broken support beam under the back deck that had swung to the ground. Downstairs, LPA observed the bathroom toilet roll holder to be missing with a large screw exposed. The bathroom light switch cover was loose with a loose nail. The dressers in both downstairs bedrooms had missing drawer knobs and sharp screws exposed where the knobs would screw on. In one of the downstairs bedrooms, there is a heavily stained mattress with a hole in it, which Administrator stated would be replaced. The window screens were torn, and the curtain rod was pulled from the wall fixture. Upstairs, LPA observed a dresser with no drawer knobs, resulting in difficulty opening the drawers. There were two large holes in the wall of one of the bedrooms, graffiti on a ceiling beam, on the window, on the dresser, and on the front and back of the door. The graffiti on the door included gang-related symbols/lettering and profanity that speaks negatively of the facility and specific staff members. The door frame is also broken. There is currently a resident in this room, and Administrator stated the graffiti and holes were caused by a former resident and that the current resident moved into the room with this damage present. Administrator stated that the resident cannot be moved to one of the vacant bedrooms downstairs due to a runaway risk. When LPA arrived, there were two residents and one staff, Administrator. One of the residents is a known runaway risk. Staffing should be increased to provide extra supervision and meet this resident's needs. Administrator provided evidence of their correspondence with licensee on getting these issues addressed. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of California Code of Regulations, Title 22, sections 80087 and 80088 and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards sections 87076 and 87065.5. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Sonam Prasad, whose signature on this form confirms receipt.

Investigation Findings:
13On 4/7/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an initial complaint inspection. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. CEO Carizma Chapman entered the facility at around 1:45PM. During the visit, LPA conducted a tour of the facility and grounds with Administrator and obtained photos. LPA observed the kitchen trash can to be placed on top of the lid, meaning it was being used without a lid. LPA observed expired food in the upstairs cabinets and refrigerator and in the downstairs emergency food supply, including rotten bell pepper, expired cans of soup and sausages, and old cereal in open bags with no boxes. The emergency food supply log was last updated on 2/19/21 and includes more food than was available in the cabinets, and much of the food was expired. Administrator confirmed more food would be purchased but also confirmed that there was a lot less food last week. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LA CHEIM STRTPFACILITY NUMBER: VISIT DATE: 04/07/2023

met_with: Administrator Sonam Prasad; CEO Carizma Chapman


summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
Additionally, facility records reveal that a 14-day notice was issued for a resident with a stipulation that the resident would not be authorized to return to the facility following another psychiatric hold or law enforcement contact. After an incident in September 2022, the resident was released from a hold, and the facility did not pick up the youth. The facility did not follow proper procedures in developing a transition plan for the resident and ensuring trauma-informed care of the resident. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87061 and Section 87068.4. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Facility Manager Tatiana Good, whose signature on this form confirms receipt.

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

Deficiencies:
87061: (C) Description of what manual restraints were used, and how long the child was restrained.

met_with: Facility Manager Tatiana Good

title:
Reporting Requirements
(i)(6) Incident Reports documenting the use of manual restraints must include the following


met_with: Sonam Prasad

investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

allegations: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


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

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


summary: Facility Evaluation

raw_content:
Narrative:
SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Oquendo 10/13/21 at 10:00AM. LPA spoke with Administrator - Sonam Prasad, who provided files and documents for review. This inspection was conducted at this facility. LPA reviewed client files and viewed the medications in the office, which were locked in a cabinet, located inside the locked staff office. Facility has a capacity of six, with three children in placement. All three of the children placed at this facility are prescribed psychotropic medications One child was present at the facility during this inspection. The other children were at school. This facility previously received an SB 484 inspection on 11/12/20. LPA conducted exit interview with administrator and left a copy of this report.