summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 09/22/23 at 9:51am, Licensing program Analyst (LPA) Christine Wilson and Licensing Program Analyst Jhane Haynes visited the above listed facility and met with AM. The purpose of the visit is to conduct a post-licensing inspection. This facility is licensed to provide care and supervision for 6 ambulatory only female children, ages 12 through 17 years old. The facility is one-story home which contains three (3) bedrooms, and two (2) bathrooms. The home has a fully equipped kitchen and a spacious living room and dining room, that can be utilized as a multipurpose room for homework and activities. The front yard, and side yard was observed to be secure with a cement fence 7ft in height , free of obstructions, and neat. The facility maintains one facility vehicle, Honda Odyssey not at the facility at the time of the inspection. There are (2) charged fire extinguishers through the facility, last inspected on 3/25/23. (1) Carbon monoxide and (5) smoke detectors were tested and fully functioning. Detergents and cleaning supplies were observed to be locked and inaccessible to minors. Medication closet located in staff office was observed to be secured and inaccessible to minors. Facility files will be maintained within the staff office. LPAs observed the following during inspection: Living Room: the living room is a large open space that functions as a area for relaxation. There is a new couch with plenty of seating for 8+ people, a TV will be purchased, books and games are available and a functioning window is still without a screen .There is a working smoke detector and a carbon monoxide detector in this space Dining Area: Has a table with seating for (4) as well a a bar with seating for (4) with cabinet space. Kitchen: equipped with a stove (2) burners, microwave, oven, refrigerator, plenty of cabinet space, and enough plates/cups/utensils for all clients. Trash cans are covered. Dishwashing machine is in working order and will not be used. Water temperature is 111 degrees. Hallway: The hallway has a (1) linen closet and maintains enough linen and towels for all residents. There is a working smoke detector in this space. (Continued on 809C Page 2) Bedroom #1: Is adjacent to the living room, will be occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There are adequate closets and (2) drawers (2). The bedroom does not serve as a passageway to any other part of the facility. Bedroom #2: will be occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There is a new area rug. There are adequate closets (2)and (2) drawers. There is a functioning smoke alarm. The bedroom does not serve as a passageway to any other part of the facility. Bedroom #3 :will be occupied by two clients and maintain two twin beds, There is adequate closet (1) and (2) drawers. There is a functioning smoke alarm.. There is still no window screen. Bathrooms- there are two (2) bathrooms throughout the facility, each with operational plumbing and running water that meets temperature requirements. Peach bathroom is shared with Bedroom 3 and staff. Blue bathroom is used for Bedrooms 1&2. Water temperature is 111 degrees. Outdoor Space- the outdoor space has concrete. The Licensee communicates that it will be used " for clients to come outside and paint" There is a gazebo structure, with an empty, non-functioning covered spa. There are wires dangling from the building that pose a safety risk when clients are in care. AM stated he will find a way to secure wires to mitigate safety risk. Laundry: located in the driveway area in a open shed and equipped with a washer and dryer in working order, Laundry detergents and cleaning supplies are kept in locked hallway closet and are inaccessible to clients without supervision. Backyard - there is an enclosed cement fence that extends around the perimeter of the facility that meets height requirements. There is no body of water on the premises. The front and side of the facility appeared clean and orderly with no hazards. Medication station- medications will be stored in a locked cabinet, in a closet in the staff office. The policy for medication administration will be posted on the inside of the door and was reviewed by LPA. Medication boxes were kept locked within the locked cabinet, with a standard key lock. Staff office- this office is located near the driveway and has laptops, a desk, and chairs. This space will be utilized for staff to conduct administrative duties, and where client records will be stored. LPA observed that door does lock. This area also functions to hold locked storage space for sharps, cleaning supplies, hygiene supplies and extra bathroom linen. There is no additional bathroom designated for staff. Licensee indicates that Bathroom #2 will be used by staff and clients. There is a functioning smoke alarm. (Continued on 809C page 3) LPA Wilson and LPA Haynes inspected the following: Conducted a review of staff records, Program Statement, Plan of Operation and Emergency Plans. LPAs conducted a staff interview with (AM). There are no clients residing in the facility at this time. Core Theraputic Services: No clients receive core theraputic, psychiatric and medical services, as part of their needs and services plan. There are no clients in care Special Health Care Needs:There are no clients with special health care . There are no clients in care PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 3, The following deficiencies were cited at this time. Six (6) Technical Advisories will be given on this day.(See LIC809-D) ILS 87072(c)(6)(A ILS 87072(c)(6)(B ILS 87087.2(a) ILS 80066(a)(8) ILS 87065.1(d)(1)(A) ILS 87065.1(d)(1)(D)(4) Three (3) Type B violations will be given on this day. (See LIC809-D) An exit interview was conducted, and a copy of this report was discussed emailed to the licensee.

Deficiencies:
80075(h): Health-Related Services

(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available

met_with: Facility Assistant Manager (AM)


state: CA

facility_name: KIDS TO KIDS - FAITH HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On March 29, 2024 at 10:00am, a Non-Compliance Conference Meeting was held virtually, with the El Segundo Regional Office. Those In attendance were: · Regional Manager (RM), Kellee Coleman · Licensing Program Manager (LPM), Kevin Sauk · Licensing Program Analyst (LPA), Christine Wilson · CEO/Administrator, David Yasutake · Facility Manager, Chris Thompson · Facility Manager, Madison Pennington · Assistant Manager, Vanessa Duarte The office meeting was called to discuss the Licensee's attempts and efforts at obtaining a Mental Health Program Approval (MHPA), in order to determine whether an extension shall be provided for the provisional license. RM Coleman provided an overview of Community Care Licensing's (CCL's) history of support towards the licensee. Kids to Kids has not yet been able to obtain a MPHA, and discussions with CCL's legal department will explore whether the Licensee will be able to extend their provisional license expiration date. The meeting included a discussion of the attempts and challenges the Licensee has been facing with regard to obtaining an MPHA, and with staffing. Continued on 809C page 2 of 2. Page The licensee (CEO) agreed to the actions specified below: Licensee is to Provide LPM and LPA weekly contact with updates each Friday. Licensee is to continue communications with DHCS and Kern County. Licensee is to explore other facility types. Licensee is to send CCLD update and/or copy of CARF Accreditation Approval. Licensee is to ensure all staff are associated to this facility through the use of Guardian. The Regional Office can support with association transfers. Licensee is to submit a closure plan if the Licensee is unable to obtain a MPHA approval by the 12-month expiration date. This meeting ended at 11:22am. Exit interview completed, and a copy of this report was emailed to the Licensee.

report_type: Facility Evaluation

met_with: Licensee - David Yasutake


summary: Facility Evaluation

raw_content:
Narrative:
On 05/31/24 at 09:50AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting annual inspection. LPA met with Madison Pennington (FM) who granted access to the facility and provided tour of the home. It is a three bedroom and two bathroom home in a residential area. LPA observed the following: Office is inaccessible to clients unless allowed for 1:1 or privacy. It contains desk, chairs, client hygiene boxes,two exterior exits,staff fridge, secured freezer for extra food stock, board with client and facility information. It also contains a secured closet that holds client medications, sharps, extra hygiene products, client files and electronics. Hall connects both bathrooms and two bedrooms. The wall contains emergency contact numbers, complaint procedures, personal rights and license. It also contains a secured closet that contains cleaning supplies. Bathroom #1 is called the peach bathroom containing functional toilet, sink and tub/shower combo. Bedroom #1 rooms C2 and contains two twin beds, two dressers and closet. Bathroom #2 is called the blue bathroom and contains functioning toilet, sink, and tub/shower combo. Bedroom#2 rooms C3 and contains two twin beds, 2 dressers, and closet. Kitchen/Dining Area contains operational kitchen appliances table and adequate seating for clients during meal times. Menu is posted on fridge. Fridge maintains perishables for at least two days. Cabinets maintain non-perishables for up to a week, adequate plating and silverware for clients. There is an exterior exit. Bedroom #3 rooms C1 and C4. It contains two twin beds, dresser, shelf, three closets and desk. Living Room contains two couches, TV, and shelf with books and games. There are two exterior exits. Exterior is free of debris and contains utility shutoffs. Laundry appliances are stored on side of the home and functional. Facility utilizes Chevrolet Tahoe with current registration and insurance to transport clients. (Continued on LIC809-C) Due to time constraints. LPA will return to complete file review. No deficiencies will be cited today. An exit interview was conducted and a copy of this report was left at the facility.

visit_type: Annual

met_with: Madison Pennington (Facility Manager)


summary: Facility Evaluation

raw_content:
Narrative:
On 05/31/24 at 09:50AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility to conduct a case management inspection for the purpose of documenting deficiency observed 04/30/24. LPA met with Madison Pennington (FM) who granted access to the facility. On 04/30/ It was observed during initial complaint inspection that 11 out of 17(S1-S11) staff did not obtain criminal record clearance. Per Title Division Chapter 1, one deficiency will be cited. See LIC809-D for details. A copy of this report and appeal rights were left at the facility.

visit_type: Case Management

met_with: Madison Pennington Facility Manager (FM)


facility_name: KIDS TO KIDS - SERENITY HOUSE

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
continued from 9099 page It was reported that FM stated the PO said to keep C1 home from school so that they wouldn't have to track C1 at school, and in other interviews it was communicated by FM with management and staff that the PO said to keep C1 home. Based on confidential interviews, and a review of supportive documentation AGPA Woodard could not corroborate that the PO requested C1 to stay home from school in order for the PO to take C1 into custody. The facility violated C1s's personal rights by not allowing C1 to go to school and also telling C1 false information in order to keep C1 at the facility while the PO was enroute to take C1 into custody. Therefore, the preponderance of the evidence standard has been met, and the Department has determined the finding is substantiated and a citation will be documented on the LIC 9099D. An exit interview was conducted, a copy of this report, LIC 9099D, and appeal rights were left at the facility.

Investigation Findings:
13On January 20, 2023 at 3:50 p.m., Associate Governmental Program Analyst (AGPA) Tonya Barnes-Woodard conducted an unannounced complaint inspection at Kids to Kids - Serenity House for the purpose of delivering the findings. Upon arrival, AGPA Woodard was greeted by Geniveve Heikes. AGPA Tonya L. Barnes-Woodard was assigned the complaint on December 2, 2022. During the investigation process, AGPA Woodard conducted confidential interviews with staff, clients and C1's Probation Officer. C1 refused to be interviewed. AGPA Woodard reviewed supportive documentation which revealed that C1 did miss school on a few days due to not waking up and/or being ill. The PO states that the facility told PO that they would be keeping C1 home from school and the PO was under the impression that C1 wasn't feeling good the day PO prearranged to pick C1 up. ***continue on 9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 31-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: 01/20/2023

report_type: Complaint Investigation

met_with: Geniveve Heikes

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On March 7, 2023 at 9:20am Licensing Program Analyst (LPA) Nancy O'Connell made unannounced inspection to the above said facility for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA O'Connell met with FM and discussed the investigative finding. On 11/29/22, the Department received a complaint alleging that minor did not receive therapeutic services while in care. During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegations. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that the minor was transferred to the above facility, at which time, was not enrolled into therapeutic services. Further confidential interviews revealed that the facility did not retain records that could confirm the provision of therapeutic services during the time that the minor was residing in the facility. Based on LPAs 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. California Code of Regulations, Title 22, one deficiency is being cited on the attached LIC 9099D Exit Interview conducted, and sent copy of this report was sent to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: 565802325

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

met_with: Madison Pennington, Facility Manager (FM)


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
--Continued from page LIC9099-- Confidential statements and record review revealed a lack of evidence to prove the alleged as information obtained indicates denial of claims that former residents were given tobacco vape pens and marijuana wax pens by facility employees. Facility staff denied providing vape pens, wax pens, alcohol or any other contraband to the residents and no evidence to support the allegations was uncovered. Based on information from confidential statements and record review, the allegations concerning Staff engaging in illegal activities with minors and that Staff are purchasing substances for minors 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

Investigation Findings:
13On June 9, 2023, at 1: 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 June 22, 2022, Community Care Licensing Division (CCLD) received allegations that Staff engaged in illegal activities with minors and that Staff purchased substances for minors while in care at the facility. The allegation was referred to CCLD Investigations Bureau, Investigator Douglas Real. On June 30, 2022, LPA Kuliema Calloway and Licensing Program Manager Kevin Sauk conducted the initial complaint inspection and met with the facility Administrator. The investigation included confidential interviews of current and former youth residents, staff members and related parties, as well as review of facility file history. (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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 06/09/2023

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

met_with: Madison Pennnington Facility Manager

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On October 11, 2023 at 1:25 pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above listed facility, and met with the Facility Manager(S1), for the purpose of concluding the investigation, and delivering findings on the above allegation. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Wilson concluded the allegation: Staff did not ensure that minor had fair and equal access to placement at the facility is unsubstantiated. During the investigative process by Licensing Program Analyst (LPA), Christine WIlson, victim could not be located, therefore all relevant parties could not be accounted for. 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. There are no deficiencies to be cited, at this time, regarding the above allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson 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: Facility Manager


raw_content:
Investigation Findings:
13On November 9, 2023 at 12:53pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above listed facility, Kids to Kids Serenity House STRTP, for the purpose of concluding the investigation on the above allegation. The investigation included confidential interviews with client, social worker, facility and administrative staff across various licensed facilities. The licensee neglegted to take immediate action, for client (C1), by not taking (C1) to the hospital after sdtaff discovered client was under the influence of drugs. Based on all interviews conducted, and documents obtained, the Department has found the above allegation to be substantiated, meaning that, the preponderance of the evidence has been met. A Type a violation is given this day An exit interview was conducted, and appeal rights were discussed. A copy of this report, and appeal rights were provided to Facility Administrator. (Continued on page LIC9099-D) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson 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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: 565802325

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


raw_content:
Narrative:
(9099C Pg.2) The facility is issued a citation in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 1, Personal Rights [See page LIC9099-D for cited deficiencies]. An exit interview was conducted, and appeal rights were discussed. A copy of this report, and appeal rights were provided to the Facility Manager and emailed to Facility Administrator. (Continued on page LIC9099-D)

Investigation Findings:
13On November 9, 2023 at 12:53pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA spoke with Program Manger (PM) and together, discussed the investigative finding. Further investigative processs by Licensing Program Analyst (LPA) Christine Wilson, included all relevant parties, and supporting evidence includes: interviews with administrative staff. Records review of section K of the Plan of Operation/Program Statement, Admissions Policies and Procedures, which states the licensee shall "ensure that there is no discrimination against any youth or NMD based on sexual orientation, gender identity or expression, religion, culture, race when considering clients for admission." Interview with the (PA) revealed the licencee normally does not admit biological males who identify as female. Based on the discrepancy between the licensee's program statement, and their intake practices, the allegation is substatiated SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson 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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 11/09/2023

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

met_with: Program Manager


raw_content:
Narrative:
Confidential statements and documentary evidence, including review of medical records determined Y1 overdosed on Fentanyl and recovered within two days after being admitted to the hospital. Y1 was then placed on watch by the hospital staff; however, Y1 was able to obtain drugs and overdosed a second time resulting in Y1's death. Based on gathered information obtained and reviewed, there is not enough evidence to support neglect/lack of supervision; therefore, the findings are 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 are no deficiencies per California Code of Regulations or Interim Licensing Standards (ILS) cited at this time. Exit interview completed. A copy of this report and LIC811 was provided to Facility Administrator by email for signature.

Investigation Findings:
13On April 9, 2024, at 4: PM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection at Kids to Kids - Serenity House to deliver findings concerning the above-mentioned allegation. LPA Martin spoke with David Yasutake, Administrator via telephone to discuss the investigative outcome. The investigation was conducted by Investigator Peter Zertuche of the Community Care Licensing Division (CCLD) Investigations Branch. The investigation, including confidential interviews of three residents, three staff members, Facility Manager, Youth #1's (Y1) assigned Social Worker, Therapist, assigned Detective, Ventura Police Department, review of Y1's records and review of related medical reports revealed on December 21, 2023, CCLD received a complaint allegation concerning neglect/lack of supervision related to Y1. Youth #1 was first placed at Kids to Kids - Serenity House on September 6. 2023. On December 6, 2023, CCLD received a self-reported incident indicating that on December 3, 2023, staff found Y1 at the facility at "6:06 am" of an apparent drug overdose. Y1 was unresponsive so 911 emergency was called. Staff performed Cardiopulmonary Resuscitation (CPR) until paramedics arrived then transported Y1 to the hospital where Y1 recovered. (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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 04/09/2024

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

met_with: Facility Representative


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA Jones-Steward interviewed several staff, several witnesses and the alleged victim (C1). LPA also reviewed police reports and the facility's runaway plan. LPA did not find a Special Incident Report for this incident. During the course of the investigation LPA Jones-Steward determined that the staff on duty during the incident waited for several hours after the onset of C1's crisis to contact law enforcement and paramedics. Likewise it was determined that staff are not adhereing to the facility's runaway plan. Staff often waits in excess of an hour to report missing clients even though the runaway plan indicates that missing clients will be reported to law enforcement within 30 minutes. It was also determined that the facility had no clear plans for accompanying C1 to the hospital or supervising her while she was there. Based on information found during the investigation, the above allegations are resolved as substantiated, meaning that the "preponderance of the evidence" standard has been met. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward 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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: 565802325

met_with: Madison Pennington, Facility Manager


facility_name: KOA HOME

raw_content:
Narrative:
Confidential interviews revealed that C1 and C2 have separate living rooms. When they are in the same room together there is always a staff member between them. None of the clients are allowed to sit on the same couch. All clients have their own bedrooms and no client is allowed in another client's room. The staff at night have a clear field of vision down the hallway and are able to monitor the clients. Based on confidential interviews and record reviews, the allegation that lack of supervision resulted in inappropriate interaction between minors C1 and C2 may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report and appeal rights were explained and given to House manager Jesse Lozano.

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: Jesse Lozano


raw_content:
Narrative:
Based on confidential interviews and record reviews, the allegation staff do not prevent minor from harm while in care may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report and appeal rights were explained and given to House manager Jesse Lozano.

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:
Confidential interviews revealed that C1 has a shower daily and that C1 is able to take care of C1's own bathroom needs. Confidential interviews and personal observation revealed that the clients backpacks are cleaned out daily and the staff know to look for dirty clothes and food in backpacks. Other confidential interviews state that the clients would let the staff know if there was food sent home as they like to eat it. A confidential witness still maintains that the allegations are true. The allegation that facility staff did not ensure the group home child was adequately and cleanly dressed specifically refers to C1 having dried feces on sweat pants, C1 not wearing underwear, and that C1 has worn the same shorts twice in one week. Confidential interviews revealed that the clients clothes are washed if not daily every other day. Confidential interviews also revealed that while the staff lay the clothes out for C1 for the day C1 will dress self and that C1 owns three sets of the exact same shorts so it seems that C1 is wearing the same shorts more than once a week however they are a new clean pair of shorts. Other confidential interviews revealed that they have not seen C1 wear the same clothes more than once without being washed. A confidential witness still maintains that the allegations are true. The allegation that group home children are not being adequately supervised specifically refers to the sexualized behavior between C1 and C2. C1 is constantly trying to touch C2's butt and breasts and C1 will thrust pelvis at C2. Confidential interviews revealed that C1 and C2 have separate living rooms. When they are in the same room together there is always a staff member between them. None of the clients are allowed to sit on the same couch. All clients have their own bedrooms and no client is allowed in another client's room. The staff at night have a clear field of vision down the hallway and are able to monitor the clients. A confidential witness still maintains that the allegations are true. Based on confidential interviews and record reviews, the allegations that facility staff is not meeting C1's hygiene needs, facility staff did not ensure that C1 was adequately and cleanly dressed, and C1 and C2 are not being adequately supervised may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report and appeal rights were explained and given to House manager Jesse Lozano.

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:
Confidential interviews and document reviews revealed that while C1 did have a black eye when C1 went to school, it could be explained. Per the Special Incident Report (SIR) dated 12/31/2021, another client slipped on C1's blanket outside their door and fell over C1. C1 had redness and scratches around their right eye. Confidential interviews reported that the staff took C1 to the doctor to have C1's eye checked. Confidential interviews stated that the medical staff performing the forensic evaluation showed no signs of abuse. The Department also received an allegation that the facility does not meet the minor's (C1) hygiene needs. It was reported that C1 comes to school soiled. Confidential interviews revealed that when C1 leaves home, C1 is clean; however, C1 sometimes has wet or soiled themselves before reaching school on the school bus. Confidential interviews reported that when C1 leaves the facility to go to school, C1 is clean, and C1's diaper is not soiled. The Department also received an allegation that the facility is not ensuring that minor (C1) have their mobility device at school. It was reported that C1 is being sent to school without their motorized scooter. Confidential interviews revealed that while C1 is not being sent to the school with their motorized scooter, they are sending C1 to school with a mobility device of a stand-up walker. The Individualized Education Program (IEP) for C1 states that C1 is to use a stand-up walker at school. Confidential interviews reported that staff was following the directives in C1's IEP regarding the device C1 was allowed to use while at school. Based on confidential interviews and record reviews, the allegations that the minor (C1) has an unexplained black eye, the facility does not meet minor's (C1) hygiene needs, and the facility is not ensuring that the minor (C1) has their mobility device at school may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to Koa Home DSP II Richard Perreno..

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: Richard Perreno


raw_content:
Narrative:
Confidential interviews reported that initially, there was no explanation for the cause of the injuries to C1. Confidential interviews reported that later, an explanation was provided that C1 scratched themself, causing minor cuts on C1's face. Confidential interviews disclosed that a cabinet door was opened near C1's face, which caused the minor cuts. The facility provided a Special Incident Report (SIR), which explained the scratches on C1's face. Confidential interviews reported that although C1 is allowed to move about the facility freely without facility staff, sometimes, as C1 is moving freely throughout the facility, C1 may open a door or cabinet. These actions sometimes cause scratches on C1's face. As part of their safety plan, the facility staff will place child-proof locks on cabinet doors to prevent C1 from sustaining injuries on C1's face. There are no corroborating statements that were disclosed that C1 injuries were caused due to lack of supervision. Based on inconsistent confidential interviews, the allegation that the minor sustained unexplained injuries while in care, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report and appeal rights was explained and given to Administrator Fernando Melendez.

Investigation Findings:
13On 02/23/2023 at 10: AM, Licensing Program Analyst (LPA) Joon Choi made an unannounced visit to deliver the investigative findings for the allegation listed above and met with Koa Home Group Home (GH) Administrator Fernando Melendez. On 03/15/2022, LPA Linda Haynes conducted an initial health and safety inspection of the facility. No immediate health and safety hazards were observed. On 02/07/2023, LPA Choi conducted a follow-up visit to the facility, and no immediate health and safety hazards were observed. LPA Haynes interviewed the House Manager (S1), and LPA Choi interviewed the Administrator (S2) and three Direct Care Staff (S3, S4, and S5). LPA attempted to interview Client 1 (C1) but could not be interviewed due to the inability to communicate verbally. On 03/09/2022, Community Care Licensing received an allegation that minor sustained unexplained injuries while in care. Confidential interviews reported that two fresh, small cuts (the size of an adult's pinky nail) were observed on the right side of Client 1's (C1) face. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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 19-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, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/23/2023

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

met_with: Fernando Melendez, Administrator


raw_content:
Narrative:
Confidential interviews reported that C1 acted agitatedly on previous returns to the facility while on the school bus. Confidential interviews reported that C1 was not agitated when S4 and S5 entered the school bus to assist. Other confidential interviews reported that the facility staff (S4 and S5) were called by the bus driver and C1's school aide, as they were having difficulty escorting C1 off of the bus. Confidential interviews reported that although the school bus driver and the school aide were responsible for escorting C1 off the bus, the facility staff members (S4 and S5) agreed to assist. Confidential interviews reported that two facility staff members (S4 and S5) utilized their Crisis Prevention Intervention (CPI) training, to escort C1 off of the bus, in the least restrictive manner. Confidential interviews reported that S4 and S5 did not have to use any physical force. S4 and S5 stood on each side of C1 and held C1's arms and shoulders to ensure C1 did not fall while walking off the bus. Confidential interviews reported that after this incident, the facility staff was instructed that C1 would be escorted off the bus, by the bus driver and/or C1's school aide only. Confidential interviews reported that no injuries were observed on C1 because of this incident. Confidential interviews reported that a Special Incident Report (SIR) submitted by the facility, was obtained, which was consistent with the statements from the confidential interviews. Based on confidential interviews and SIR obtained, the allegation that a staff member (S4) handled the minor (C1) in a physically aggressive manner, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report and appeal rights was explained and given to Administrator Fernando Melendez

Investigation Findings:
13On 02/23/2023 at 09: AM, Licensing Program Analyst (LPA) Joon Choi made an unannounced visit to deliver the investigative findings for the allegation listed above and met with Koa Home Group Home (GH) Administrator Fernando Melendez. On 04/26/2022, LPA Linda Haynes conducted an initial health and safety inspection of the facility. No immediate health and safety hazards were observed. On 02/07/2023, LPA Choi conducted a follow-up visit to the facility, and no immediate health and safety hazards were observed. LPA Haynes interviewed the Clinical Director (S1), and LPA Choi interviewed the Administrator (S2) and three Direct Care Staff (S3, S4, and S5). LPA attempted to interview Client 1 (C1) but could not be interviewed due to the inability to communicate verbally. On 04/21/2022, Community Care Licensing received an allegation that a staff member (S4) handled the minor (C1) in a physically aggressive manner. Confidential interviews reported that when C1's school bus arrived at the facility, C1 saw a facility staff member (S4 and S5) approach the bus, at which point C1 became agitated. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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 19-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, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/23/2023

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

met_with: Fernando Melendez, Adminstrator


raw_content:
Narrative:
The facility provided a Special Incident Report (SIR), which explained the scratches and bruising on C1's forehead and left eye. Confidential interviews reported that although C1 is allowed to move about the facility freely without facility staff, sometimes, as C1 is moving freely throughout the facility, C1 may open a door or cabinet. These actions sometimes cause scratches and bruising on C1's face or body. As part of their safety plan, the facility staff will place child-proof locks on cabinet doors to prevent C1 from sustaining injuries on C1's face. There are no corroborating statements that were disclosed that C1 injuries were caused due to lack of supervision. Based on confidential interviews and SIR, the allegation that the child sustained unexplained injuries while in care, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report and appeal rights was explained and given to Administrator Fernando Melendez.

Investigation Findings:
13On 02/23/2023 at 09: AM Licensing Program Analyst (LPA) Joon Choi made an unannounced visit to deliver the investigative findings for the allegation listed above and met with Koa Home Group Home (GH) Administrator Fernando Melendez. On 05/10/2022, LPA Linda Haynes conducted an initial health and safety inspection of the facility. No immediate health and safety hazards were observed. On 02/07/2023, LPA Choi conducted a follow-up visit to the facility, and no immediate health and safety hazards were observed. LPA Haynes interviewed the Clinical Director (S1), and LPA Choi interviewed the Administrator (S2) and three Direct Care Staff (S3, S4, and S5). LPA attempted to interview Client 1 (C1) but could not be interviewed due to the inability to communicate verbally. On 05/06/2022, Community Care Licensing received an allegation that the child (C1) sustained unexplained injuries while in care. Confidential interviews reported that C1 had a scratch and a bruise on their left eye about an inch long, three bruises on C1's forehead about two inches long, and the color was reddish-brown. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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 19-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, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/23/2023

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


raw_content:
Narrative:
Confidential witnesses revealed to LPA that staff provide appropriate supervision to C1 and the other clients. Furthermore, confidential witnesses stated that facility staff were always present and engaged with the clients. CSW indicated that C1 would have tantrums and C1 would roll on the ground. CSW added that C1 was physically aggressive toward staff and peers and staff were always appropriate with C1 with redirection. CSW didn't believe there was a lack of supervision resulting C1 sustaining an injury. Other confidential witness interview revealed that they had observed C1 with unexplained injuries. Based on confidential interviews and record reviews, the allegation that due to lack of supervision C1 had a bruise on C1's back on September 8, 2022, may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Fernando Melendez.

Investigation Findings:
13On September 28, 2023, at 2: PM Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with facility staff, Fernando Melendez, to issue the finding for the above stated allegation. The complaint investigation was jointly conducted by LPA J. Choi, LPA L. Haynes, and LPA M. Almaraz. On September 20, 2022, at 2: PM, LPA Choi arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA Choi also reviewed one client's (C1) records see confidential names list (LIC 811) dated September 28, 2023. Additionally, LPA Almaraz conducted interviews with four staff, a county social worker (CSW), three confidential witnesses, and four of four clients. LPA didn't receive responses from three of four clients due to being non-verbal. On September 12, 2022, the Department received a complaint that alleged a minor sustained a bruise while in care. More specifically, it was alleged that due to lack of supervision C1 had a bruise on C1's back on September 8, 2022. During the course of the investigation, confidential witnesses stated that C1 tends to have tantrums where C1 will roll on the ground. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz 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 19-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, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 09/28/2023

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

met_with: Fernando Melendez


summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2026 at 10: AM Licensing Program Analyst Linda Haynes met with Koa Group Home Administrator (AD) Fernando Melendez for a case management visit inspection. The purpose of the inspection was to address issues and concerns observed during the review of an incident that occurred on or around 12/03/2025. LPA reviewed the surveillance video and observed that on December 3, 2025, S1 worked the night shift at Koa Group Home. On 12/08/2026 a search on Guardian was completed and S1 was not associated to the facility. LPA spoke with AD and was advised that S1's fingerprints were cleared in Guardian to work for their adult facilities ran by the Licensee. LPA reviewed the Person Summary in Guardian for S1 and observed that S1 had not been cleared to work at Koa Group Home as they had not been fingerprinted again and no Child Abuse Index Check (CACI) had been completed. Based upon surveillance video and record review the facility is being cited for 80019 (e)(2), Criminal Record Clearance - all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility Obtain a California clearance or a criminal record exemption as required by the department. The facility will be issued an immediate civil penalty of 500 dollars An exit interview was conducted a copy of this report, LIC 809D, LIC 421BG, and appeal rights was provided to Administrator Fernando Melendez.


raw_content:
Narrative:
Other information obtained stated that the allegation is true. Based on confidential interviews, video surveillance, and record review, the allegation that staff did not provide adequate supervision to C1, may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to Administrator Fernando Melendez.

Investigation Findings:
13On May 06, 2026, at 10: PM, Licensing Program Analyst (LPA) Linda Haynes met with Koa Group Home Administrator Fernando Melendez. On 12/05/2025, LPA conducted a health and safety inspection of the facility and there were no deficiencies found at that time. LPA reviewed the client and staff records. LPA conducted confidential interviews with Client 1 (C1), Administrator (AD), Staff 2, and Clinical Director (CD). LPA attempted to interview S1 however, S1 could not be reached. On December 03, 2025, the Department received a complaint alleging that staff did not provide adequate supervision to minor. The allegation that staff did not provide adequate supervision to minor, specifically refers to C1 being found by a bystander wandering the streets for hours. Confidential interviews revealed FC1 left the facility through their bedroom window. Confidential interviews and video surveillance further revealed that S2 did bed checks at 4: AM and the client was in their room, and again at 5: AM at this time the client was no longer in the room. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Linda Haynes 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 05/06/2026

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


facility_name: KOINONIA BHP - AUBURN

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Based on interviews conducted, it was reported that the youth was taken to the Emergency Room to be evaluated for a broken thumb on 9/12/22. Documents review also showed that youth was taken to the Emergency Room on 9/12/22. The youth was discharged from the facility on 9/19/22. Therefore, the facility was unable to complete a follow up appointment. Based on interviews, it was reported that the youth completed a follow up with the youth's new placement. Although the allegations 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: Yaseem Sandoval, Administrator


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
Based on interviews and document reviews, 3/3 children were not enrolled in school at the time of LPA's visit on 9/27/22. C1 was placed on 8/30/22 and discharged on 10/5/22. C1 was not enrolled during C1's placement with the facility. C2 was placed on 9/8/22 and discharged on 9/19/22. Although C2 was placed for a short period of time, there were no documentation showing attempts of school enrollment. C3 was placed on 9/14/22 and was not enrolled until 10/4/22. 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. California Code of Regulations, Title 22, Personal Rights Welfare and Institutions Code section 16001.9, are being cited on the attached LIC 9099D. An exit interview was conducted with the Administrator. A copy of this report was provided to the agency.

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

Deficiencies:
40721: 1
2
3
4
5
6
7

title:
2
3
4
5
6
7Personal Rights 84072 Welfare and Institutions Code section 16001.9 (27) To attend school, to remain in the child's school of origin, to immediate enrollment upon a change of school,..)
This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


raw_content:
Narrative:
the client was close to a table where they could have hit their head when resisting strenuously and the kitchen flooring made for an unstable surface as the chairs were sliding and the youth was able to get on the floor with their head close to the chair seat. The client also has a significant history of aggressive and impulsive behaviors that needed to be taken into consideration to prevent or minimize the potential need for restraining and this was this particular staff's first time working with the client. Additionally, the restraint started in the front yard where there are no cameras and conflicting versions of what happened were reported. Because general protocol was exercised and there is some discrepancy of what happened, 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:

met_with: HFT Director


raw_content:
Narrative:
Confidential interviews were conducted with nine individuals during the period of 09/16/2022 to 01/26/2023, and attempted with seven individuals during the period of 11/21/2022 to 01/26/2023. LPA's observation, interviews conducted, and records reviewed were inconsistent that facility staff did not prevent youths in care from engaging in physical altercations. The facility accepts clients with severe behavioral and mental health diagnosis, and most of the incidents and physical or verbal altercations in the facility stem from clients antagonizing one another. Clients interviewed reported they like residing at the facility, feel safe and that staff separate them during altercations, and ensure their needs are met. There is evidence that the two incidents which occurred on 09/10/2022 were addressed appropriately by staff on shift to ensure safety of all clients in care, when clients escalated and engaged in physical altercations with one another. The facility Program Statement states, "When residents become engaged in physical altercations (fights) in which they do not respond to staff's verbal directives, staff may use physical interventions that include standing between the combative clients and/or physically breaking up the fight by holding back a client by his/her shoulders while verbally re-directing him/her." And "In cases where a client(s) ... does (do) not respond to re-direction... de-escalation techniques are used and law enforcement and/or the case manager is contacted depending upon the seriousness of the incident." Review of other documentation described the client's behaviors and needs which were outlined on their Individual Needs and Services Plans, and facility staff completed Safety Plans with clients in care, to identify triggers to behaviors and ways for clients to regulate their feelings. Upon review of the Incident Reports, and information gathered through interviews, at the time of the altercations, staff had offered coping strategies to clients, separated the clients per facility policy and the Police Department was contacted to support in de-escalating the aggressing clients. Through interviews, multiple staff reported that the Police Department will be contacted by request support at the facility when clients are a danger to themselves or others. The department has conducted a complaint investigation regarding the allegation: Facility staff did not prevent youths in care from engaging in physical altercations. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No citations were issued during this inspection. An exit interview was conducted with and a copy of this report was provided to Bill Ryland, Homes for Teens Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above agency on January 26, 2022 at 1: PM and met with Bill Ryland, Homes for Teens Director. The purpose of the inspection was to deliver complaint findings for the above allegation. On September 16, 2022 at 11: AM, Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility to initiate a complaint investigation related to the above allegation. LPA met with Diana Macneill, Interim Facility Administrator and Yasmeen Sandoval, Facility Administrator. LPA completed a physical inspection of the group home, inside and out. During the course of the investigation, the following documents were gathered and reviewed: Incident Reports for three youth, Police Reports regarding the 09/10/ Incidents involving FC1, and FC3; Resident Assessments for three youth, Face Sheets for two youth, Needs and Services Plans for four youth, Placement Referrals (Kaiser) for three youth, Client census log, Staff Roster and Schedules, Program Daily Schedule, Safety Plan for FC3, Emotional Regulation Action Plan for FC1 and FC4, and the Pre-Teen Behavioral Health Program Statement. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna 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 NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: KOINONIA BHP - AUBURNFACILITY NUMBER: VISIT DATE: 01/26/2023

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

met_with: Bill Ryland, Homes for Teens Director


raw_content:
Narrative:
Confidential interviews were conducted with twelve individuals during the period of 09/16/2022 to 01/26/2023, and attempted with seven individuals during the period of 11/21/2022 to 01/26/2023. The department has conducted a complaint investigation regarding the allegation: Staff restrained minor in care. There was insufficient evidence to state that staff inappropriately restrained a minor in care. Upon review of incident reports, and based on information gathered during interviews, restraints are permitted to be conducted as a last resort when there is a safety concern of danger to a youth or others, and is to be conducted by two CPI trained staff, including pertaining FC1. Per review of the facility Program Statement, "Physical intervention should only be used as a last resort, when all other attempts to defuse the crisis situation using non-physical means have been tried and found ineffective. They will only be used when an individual presents a danger to self or others and when the risks posed when an individual presents a danger to self or others." Staff who utilized restraints were CPI trained, and Incident Reports reviewed documented there was one restraint conducted in the month of September 2022 (on 09/28/2022). Incident Reports and staff interviewed both stated that there was a need for the restraint due to the youth being a danger to self or others, and after other de-escalation techniques were attempted and unsuccessful. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report was provided to Bill Ryland, Homes for Teens Director. Confidential interviews were conducted with twelve individuals during the period of 09/16/2022 to 01/26/2023, and attempted with seven individuals during the period of 11/21/2022 to 01/26/2023. The department has conducted a complaint investigation regarding the allegations: Staff did not provide a safe environment for children, Facility has insufficient staffing to meet children's needs, Staff do not report incidents as required, and Staff are not adequately trained to meet the needs of children in care. Based on interviews conducted, a staff reported they were asked to go home without completing an Incident Report on 09/10/2022, and another staff reported that they do not recall filling out an incident report for the incident involving FC1 on 09/10/2022. Review of incident Reports for three youth in care included incidents involving youth absence without permission, youth aggression and threats, and property destruction. The Incident Report pertaining to FC1 on 09/10/2022, could not be provided from the facility, and there is no evidence that the Law Enforcement Incident Report had been completed or submitted to the department as required. There was sufficient evidence to support that the facility had insufficient staffing to meet the children's needs. Based on review of clients' Needs and Services Plans and Assessments, documentation of the need for clients to have one on one or additional staff was not documented. Upon review of the facility's Program Statement, it states "During awake hours a minimum of two staff will be on duty at all time, 24 hours and day, 7 days a week. Depending on occupancy, the targeted awake ration is 1 staff to 2 youth." Based on review of staff schedules and time sheets, there were times when serious incidents occurred, but there was only one staff on shift, leaving youth in care with unmet safety needs. The physical environment of the facility was observed to be free of hazards during the Department's physical inspection of the facility, however through interviews and record reviews it was determined that staff present during multiple interventions were not sufficiently trained or capable in their skills to support the needs of the children in care, therefore not providing a safe environment. Upon review of Crisis Prevention Intervention (CPI) certificates, nine staff who worked at the facility did not complete training and obtain their certificates until 09/28/2022, however this was within the required 90 days after their hire date. continued on 9099-c Based on LPA observations, documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The facility is being issued three citations related to the complaint investigation and pertaining to deficiencies to the following regulations, Group Home ILS section 84065.5(c) If the children require special care and supervision because of age, problem behavior or other factors, the number of on-duty child care staff shall be increased; section 84061(i) The licensee shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child residing in the facility; and section 84065(i)(2) Sixteen hours of training shall be completed by new child care staff within 90 days of hire. An exit interview was conducted and a copy of this report and appeal rights were provided to Bill Ryland, Homes for Teens Director. Through record review of time sheets, it was determined that these staff completed their shifts while on shift with at least one CPI trained staff person during the month of September. Upon review of the facility's Program Statement, "If assaultive behavior continues to be displayed and a clear risk is perceived, staff may employ a team physical intervention as a last resort. Generally, this will involve the use of the CPI Team Control technique, with two staff members involved ensuring that the service user's upper and lower body strength is restricted, along with their mobility." Based on review of Incident Reports, assaultive behaviors from FC1 and FC3 did occur at the facility during the month of September, and while there was a minimal or inconsistent amount of CPI trained staff present, presenting an unsafe environment for clients in care, as well as staff. Due to staff not being able to physically intervene when appropriate, utilizing CPI curriculum, staff contacted Law Enforcement as an alternative to de-escalate youth who were threatening, or acting aggressively, toward youth in care and staff present, as a way to de-escalate unsafe situations. There was consistent evidence to determine that staff are not adequately trained to meet the needs of children in care, including interviews conducted with two staff who stated they did not receive initial or thourough training, felt unprepared and unsupported and were not given additional time to complete required training while on shift. Based on a review of the facility's Program Statement, it stated," All direct care staff shall receive two full days training in CPI Nonviolent Crisis Intervention® within three months of commencing in their post.." and "An additional 16-Hour training will be completed of the new direct care staff within 90 days of hire." Upon review of CPI certificates, nine staff who worked at the facility did not complete and obtain their certificates until 09/28/2022, however this was within the required 90 days after their hire date. Additionally, based on a review of training documents and certificates, it was determined that at the time of the incidents occuring in September 2022, the required 16 hour initial training for new staff was not yet due, with the due date being 90-days after their hire date. However, this training was either not completed or was not completed within the 90-day time-frame, as of February 07, 2023, for five out of ten staff whose training documentation was reviewed for a second time. continued on 9099-c

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above agency on February 07, 2023 at 02: PM and met with Bill Ryland, Homes for Teens Director and Canaan Sampson, Facility Administrator Supervisor. The purpose of the inspection was to deliver complaint findings for the above allegations. On September 16, 2022 at 11: AM, Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility to initiate a complaint investigation related to the above allegation. LPA met with Diana Macneill, Interim Facility Administrator and Yasmeen Sandoval, Facility Administrator. LPA completed a physical inspection of the group home, inside and out. During the course of the investigation, the following documents were gathered and reviewed: Incident Reports for three youth, Police Reports regarding the 09/10/ Incidents involving FC1, and FC3; Resident Assessments for three youth, Face Sheets for two youth, Needs and Services Plans for four youth, Placement Referrals (Kaiser) for three youth, Client census log, Staff Roster, Schedules, Time sheets, Program Daily Schedule, Safety Plans for three youth, and the Pre-Teen Behavioral Health Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna 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 NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: KOINONIA BHP - AUBURNFACILITY NUMBER: 317006155

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:


raw_content:
Narrative:
out of 11 interviews stated that there were room checks every 10-15 minutes throughout the night as well as if youths are in their room together. Also, there were no internal reports regarding any inappropriate interactions with staff and youth during the time frame that C1 was placed at this location. Lastly, due to C1's history of not telling the truth, their guardian reportedly held no concerns over their placement there. Although the allegations may have happened or is valid there is not a preponderance of evidence to prove the alleged violations did occur therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and Appeal Rights were discussed with Terri Anderson, Facility Administrator. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On Februrary 21, Licensing Program Analyst (LPA) Sarina Buchannan conducted an unannounced visit to the Koinonia BHP Rocklin for the purpose of deliver findings to the above facility. LPA met with Terri Anderson, Facility administrator and was granted entry. During the investigation, LPA conducted the 10-day inspection of the facility on 10/02/2024. LPA obtained Staff schedules for August and September of 2022 with contact information, Facility Sketch, Client Roster, Facesheets, Needs and Service plans, Last 2 months of notes and records for the home. LPA and Investigator Brianna Abeyta conducted 11 confidential interviews between November 2024 and February 2025. Based on interviews conducted throughout the investigation, LPA received inconsistent statements. 9 of 11 interviews all stated that there are multiple staff on a shift with the youths and they are never left alone with another youth. (report continued on 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sarina Buchannan 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 BHP - AUBURNFACILITY NUMBER: VISIT DATE: 02/21/2025

met_with: Terri Anderson, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/14/22 at 9:48am, Licensing Program Analyst (LPA) Stephanie Lor and Licensing Program Manager (LPM) Rosa Rodriouez conducted a Pre-Licensing Inspection, Component II and Component III at the above facility. LPA Lor and LPM Rodriguez met with the Administrator and Director. The facility consisted of a formal living room equipped with a set of couches, a covered fireplace, a desk for staff, a formal dining room equipped with a large table with 6 chairs. There is a resting area/second living room area equipped with a TV, a covered fireplace, board games, a shelf, and 3 couches. The kitchen was equipped with counter space, a working stove, locked cabinets to store the sharp objects/knives and dish soaps, plates, utensils, cups, silverware, and a large trash can with lid on. There is an area with 6 desks/chairs and 1 desk for staff, 1 office room will be used for staff and to lock the files and medication. There were hygiene products and cleaning supplies in the closet. There are 3 bedrooms equipped with two twin size beds, closets, 2 dresser, 2 night stand and storage. Bedroom #1 is equipped with a private bathroom. Laundry room equipped with a washer/dryer and lock cabinets to store the laundry/detergent soap. The backyard has a shed used for storage. There is small river creek accessible to clients and a sitting area with a table and chairs. There is a green thumb area for planting vegetables. The front yard was clean and free of hazards. The telephone land line and internet service were in working order. The water temperature was tested and it was at 140 degrees. There was plenty of perishable/non-perishable food available. The hallway cabinet has linens and towels. The garage has 2 freezers, 1 refrigerator filled with food, exercise equipment. There were can goods stored in the garage. There are cameras in the living room, garage, classroom area, dining room and hallway. (see 2nd page) During the Inspection, LPA Lor and LPM Rodriguez observed the following: 3 first aid kits which was missing the instruction booklet, 3 fire extinguishers, carbon monoxide and smoke detector system was tested and in working condition. Component II was completed on 6/15/22 with the Director via Teams and the following areas were discussed: table of content LIC 9106 page 7 age range, section Education Rights, section House Rules, section Discipline Policies, and section Chores. Component III was also completed during today's inspection and the following forms were reviewed with the Regional Program Director: LIC198A -Child Abuse Central Index Check for State Licensed Facilities (family child care homes; children's residential homes and facilities; and adult residential facilities if, through an approved exception or a specialized license, they provide care to a person under age 18), LIC198B - Out-of-State Child Abuse/Neglect Report Request, ·LIC 306-Reporting Requirements to Department. of Social Services, LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, LIC 501 - Personnel Record, LIC 503 - Health Screening Report (including TB Clearance), LIC 508 -Criminal Record Statement, LIC 508D - Out-of-State Disclosure & Criminal Record Statement, LIC 613B - Personal Rights, LIC 624 -Unusual Incident/Injury/Death Report, LIC 627B - Consent for Medical Treatment, LIC 9058 - Applicant/Licensee Rights, LIC 9182 - Criminal Background Clearance Transfer Request, LIC Criminal Record Exemption Transfer Request, Appendix D - A Guide to Safeguarding Resident/Client Cash Resources, LIC 311B - Records to be Maintained in a Group Home, LIC 311E - Records to be Maintained in a Small Family Home, LIC 313 - Evidence of Program Consultant (Group Homes), · LIC Identification and Emergency Information, LIC 602 - Physician's Report for Community Care Facilities, LIC 603 - Preplacement Appraisal Information, LIC 622 - Centrally Stored Medication and Destruction Record, LIC 625 - Appraisal/Needs and Services Plan, LIC 9106 - Group Home Program Statement, LIC 9106A - Short-Term Residential Therapeutic Program (STRTP) Statement General Instructions, LIC 9128 - Foster Family Agency Program Statement, Neighborhood Complaint Policy (see 3rd page) Administrator will purchase a new first aid kid, replace the light in one of the bedrooms and lower the water temperature. Exit interview conducted with the Administrator and a copy of the report will be emailed to the facility.

visit_type: Prelicensing

met_with: Patti Ambriz, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility and an inspection was completed on today's date. An inspection was completed of the inside and outside of the facility. It was observed during a physical inspection of the facility that the staff office was unlocked and a filing cabinet inside the staff office, containing the client records, was left unlocked, allowing clients and other unauthorized visitors to have potential access to the client files. A Technical Advisory - Technical Violation was issued related to the inspection and California Code of Regulations, Title 22, division 6, chapter 1, section 80070(c)(1) The licensee shall be responsible for safeguarding the confidentiality of record contents. A copy was this report was left with Diana Macneill, Interim Facility Administrator


facility_name: KOINONIA BHP - LOOMIS

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
It was reported during the interview process that C1 did not have a history of lying. Staff confirmed that clients were not being monitored every fifteen minutes during the night, and the facility was not able to provide video footage to prove that the room checks were consistently completed throughout the night. Lastly, Staff reported that C2 has a history of inappropriate behavior. Based on LPA observation and interviews which were conducted and records review, Preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 5, 84072(d)(19) Personal Rights is being cited on the attached LIC 9099D. Exit interview was conducted, Appeal Rights were discussed with Juan Magallon, Facility Administrator and copy of this report were left at the facility.

Investigation Findings:
13On 8/28/2024, 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 Juan Magallon, Facility Administrator and was granted entry. During the investigation, LPAs Farhaan Sarangi and Sara Luman-Gonzalez conducted the 10 day inspection of the facility on 1/29/2024, no deficiencies were cited at that time. LPA obtained Needs and Services Plans, Case Notes from October 2024 to January 2024, Incident Reports for all clients from October 2024 to January 2024, Staff Roster for both December and January, and Client Roster for December and January. IB Investigator Sergio Guerra conducted 12 confidential interviews between December 2023 and August 2024. Based on the forensic interview conducted on 1/30/2024, C1 was consistent with the timeline of events. Even though C2 denied the allegation, C3 and C4 confirmed that C1 was victimized by C2. 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 BHP - LOOMISFACILITY NUMBER: VISIT DATE: 08/28/2024

met_with: Juan Magallon, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 22, 2021 at 12:00PM License Program Manager, Rosa Rodriguez (LPM), and License Program Analyst, Yuvi Diaz (LPA) conducted Prelicensing Inspection of this facility. LPM and LPA met with administrator, Bill Ryland who gave a tour of the interior and exterior areas of the facility's physical plant. The backyard has a pool with a fence that is at least five feet tall that meets Title 22 regulations, the fence does not obscure the view, and it has a self latching device. The front and back yards were free of clutter; No potentially hazardous items or areas were observed. The facility consisted of a kitchen, dining room space, living room space with clean couches, large TV, game room/group room, three bedrooms furnished with two beds, night stand and dresser, two bathrooms, one staff bathroom ,one office space and clinician office. License, personal rights, and disaster plan were all posted in the facility. The temperature in the room was at 70. Fire extinguisher was up to date. LPA and LPM also noted the facility had two refrigerators with at least 7 days worth of non-perishables and 3 days worth of perishables. LPA/LPM noted locked cabinets for client files and medications to be stored in a safe location.. No structural defects to the house was observed by LPA/LPM: the windows and window screens were in good repair and there were no unfinished areas. Fire alarms and carbon monoxide alarms were working. First aid was fully stocked. All domain of the tool were completed: Physical plan, operations, disaster preparedness, and client records. An exit interview was conducted with administrator. A copy of this report will be emailed to the administrator.

met_with: William Ryland


summary: Facility Evaluation

raw_content:
Narrative:
On 8/4/22 at 10:30am, License Program Analyst, Stephanie Lor (LPA) conducted a post-licensing inspection at the above facility. LPA met with Facility Administrator who gave a tour of the interior and exterior areas of the facility. All required posters were posted by the front entrance. Bedroom 1, 2, and 3 have 2 twin size beds, closets, trash cans with lids, and working lights. All 3 bathrooms had running water and the water temperature was at 117. There is 1 staff office. The hallway closet consisted of hygiene products and towels. Living area 1 consisted of a couch, desk and a piano. Living area 2 consisted of 2 couches, 2 tables, tv, locked cabinets, art supplies storage, a locked closet for the washer and dryer, and a locked closet for an extra refrigerator and pantry with at least 7 days' worth of non-perishables and 3 days' worth perishable. The backyard has a pool with a fence that is at least five feet tall that meets Title 22 regulations, and it has a self-latching device. The locked shed consisted of youth's personal belongings. There were cameras observed in the common areas. Fire alarms and carbon monoxide alarms were working. There were 2 fire extinguishers and 1 first aid kit. LPA reviewed 2 youth files, 3 staff files, and interviewed 1 youth. Two technical assistance were provided during this inspection. All domains of the tool were completed: Physical plan, operations, disaster preparedness, emergency intervention, staffing, and client records. An exit interview was conducted with administrator. A copy of this report will be emailed to the administrator.

met_with: Jordan Myers, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/19/22, License Program Analyst, Stephanie Lor (LPA) conducted an annual inspection at the above facility. LPA met with Facility Administrator who gave a tour of the interior and exterior areas of the facility. Prior to the inspection, LPA reviewed: annual fees, administrator certificate, accreditation, expiration date, waivers and exception, and personnel roster. All required posters were posted by the front entrance. Bedroom 1, 2, and 3 have 2 twin size beds, closets, trash cans with lids, and working lights. LPA Lor observed a hole in bedroom #1. Administrator provided a work order proof of the work in progress. All 3 bathrooms had running water and the water temperature was at 105 degree. There is 1 staff office. The hallway closet consisted of hygiene products and towels. Living area 1 consisted of a couch, desk and a piano. Living area 2 consisted of 2 couches, 2 tables, tv, locked cabinets, art supplies storage, a locked closet for the washer and dryer, and a locked closet with an extra refrigerator and pantry with at least 7 days' worth of non-perishables and 3 days' worth perishable. The backyard has a pool with a fence that is at least five feet tall that meets Title 22 regulations and it has a self-latching device. The locked shed consisted of youth's personal belongings. There were cameras observed in the common areas. Fire alarms and carbon monoxide alarms were working. There were 2 fire extinguishers and 3 first aid kits. The 2 vehicles were observed to be in good repair. LPA reviewed 2 youth files, 5 staff files, interviewed 2 clients, and interviewed 2 staff. 2 type B citations were given for torn window screens and a broken door closet. A Technical Violation was given to install screen windows to bedroom#3. This report was discussed with the Facility Administrator and a copy was provided to the facility.

met_with: Jordan Meyer, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/30/22, Licensing Program Analyst (LPA), Stephanie Lor conducted a case management over the phone to follow up on the annual inspection on 12/19/22. LPA Lor spoke with the Administrator regarding their phone call and house rule policy. The Administrator went over their policy with LPA Lor. The requested documents were emailed to LPA Lor on 12/21/22. LPA Lor reviewed the Program Statement and it was determined that no violations have occurred. An exit interview was conducted with the Administrator and a copy of this report will be emailed to the facility. This case management investigation is closed.


summary: Facility Evaluation

raw_content:
Narrative:
On this day January 29, 2024, Licensing Program Analysts (LPAs) Sara Luman-Gonzalez and Farhaan Sarangi conducted a Case Management-Other inspection. LPAs met with Facility Administrator, Jordan Myers and was granted access into the facility. During the Case Management-Other inspection, LPAs observed that the pool fence did not have a lock on it. LPAs educated the Administrator regarding the importance of having locks on the pool (See LIC 9102-Technical Violation). No deficiencies were cited during today's Case Management-Other inspection. Exit interview was conducted, and a copy of this report was given to the Administrator.

met_with: Jordan Myers- Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Orlando Areizaga and Sara Luman-Gonzalez made an unannounced Annual inspection on Thursday December 19, 2024 at 9: AM. During the inspection LPAs met with Canaan Juan Magallon, Facility Adminsitrator who assisted with the inspection. LPAs Areizaga and Luman-Gonzalez conducted a walk-through of the facility interior and exterior. Facility staff client ratio at time of inspection were 2 staff to 3 youths in care. Number of staff interviewed Number of clients interviewed LPAs observed # 3 bedrooms, # 3 bathrooms LPAs Areizaga and Luman-Gonzalez inspected and/or reviewed the following: Physical Plant: LPA's observed the necessary documentation, such as the Emergency ID form, License, Personal Rights, and Grievance Policies. There are 3 working phones throughout the facility. Cleaning/Disinfectants were locked along with Laundry Supplies. Smoke Detectors/Carbon Monoxide were tested and observed in working order. Fire Extinguishers were charged and in two locations in the facility. Multiple First Aid Kits were observed throughout the facility to be fully stocked. Fridge was below 45 degrees and Freezer was below 0. Hot water was tested at 110 degrees. Menu for the week was posted on the door. 2 weeks of Non-perishable items and 5 days of perishable items were observed in the kitchen area. Common areas were easily accessible with plenty of seating space for staff and youths placed at the facility. Medication centrally stored is locked/inaccessible. Office is locked. Toilets wash basin, bath and shower fixtures in good repair/no leaks. Soap and Paper towels in the restroom. Laundry Facilities with schedule in a central area. (Page 1 of 3) Bedrooms-required linen and furnishings were observed in the home. Bedroom (required bedding/furniture, furniture were observed in good repair. Two Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts. Facility free of vermin. Locked Facilities (open locked storage area/building/sheds) were accessible to the Department. Operations: Complaint Procedures For Youth Reviewed and are posted in the entryway. Board Minutes Reviewed. Disaster Preparedness: Disaster and mass casualty plan updated and available in the entryway. Quarterly Drills conducted and documented in a separate binder. Disaster preparedness supplies verified in a closet in the office. Emergency Intervention: Review of manual restraint log; No restraints within the year. Staff training is up to date. Staffing/Volunteers: Number of Staff files reviewed: 5. All Criminal Record Clearances, First Aid, CPI, Job Title/Qualifications. and Training were verified. Administrator Certificate verified. Client Records: Clients files reviewed: 5. Needs an Services Plans, Psychotropic Medications, Centrally Stored Medications, Cash Resources and Compatibility Assessment were observed in their respective binders. Core/Therapeutic Services: Trauma Informed Practices are implemented as a part of the core of the Facility. Other forms of therapy, Equine, are used with the youths. (Page 2 of 3) The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees: $454.00 · Administrator Certificate for: Juan Magallon · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions An exit interview was conducted with Juan Magallon, Facility Administrator and a copy of this report was left at the facility.


facility_name: KOINONIA BHP - ROCKLIN

raw_content:
Narrative:
In addition, there were no documentations of meeting with responsible parties to discuss the client's discharge from the program. Lastly, the responsible party was not aware or informed of any 14 days' discharge notice from the placement. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 5 are being cited on the attached LIC 9099D. An exit interview was conducted with the Administrator. A copy of this report and the Appeal Rights were provided to the agency.

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

Deficiencies:
84068.4(b): 1
2
3
4
5
6
7

met_with: Katie Danner, Administrator

title:
The licensee shall ensure that the child and his/her authorized representative(s) are offered the opportunity to participate in the development of a discharge plan for the child.
This standard is not met as evidenced by

description:
1
2
3
4
5
6
7


raw_content:
Narrative:
Based on the interviews conducted, there were no collaboration that staff abandoned minor at the hospital. When interviewing C3, C3 reported that staff S2 was with C3 the entire time at the hospital. C3 stated that the only time C3 was alone was when the staff stepped out to use the restroom, but a security guard would supervise C3. Another youth confirmed that staff never left them alone at the hospital. In addition, S2 denied leaving youth at the hospital. When interviewing other facility staff, staff could not confirm whether C3 was left alone or not at the hospital. It was reported that they've only heard of the incident from other staff. 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 the Appeal Rights were provided to the agency.

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

met_with: Dustin Blum, Administrator