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

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

met_with: Dave Yasutake, Administrator


state: CA

facility_name: KIDS TO KIDS - SERENITY HOUSE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

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

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

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

report_type: Complaint Investigation

met_with: Staff#1 (S1)

complaint_status: unsubstantiated


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

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

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

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


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

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

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
LPA Rosas and AGPA Barnes-Woodard conducted interviews with clients and facility staff that provided information that on 05/14/2021, Client#1 (C1) was video recorded by personal cell phone by Staff#2 (S2). The facility provided LPA Rosas with personal cell phone policy. LPA Rosas inspected the facility on 07/28/2022 and found no video recording cameras in the outside of the facility. Staff#3 (S3) confirmed that outdoor ring camera was removed after the incident. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated. Based on interviews on 05/14/2021, Staff#2 (S2) did recorded Client#1 (C1) with personal cell phone which infringes on C Personal Rights and poses a potential Health, Safety or Personal Rights risk to residents in care. One deficiency was observed (refer to LIC 809D) and facility is cited for violation of Interim Licensing Standards (ILS), Short Term Residential Therapeutic Program (STRTP) Version 4, Article 6. Continuing Requirements: Personal Rights 87072 (11) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, *exploitation,* infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On September 1, 2022, at 09:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Serenity House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted inspection and conducted interviews. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated September 1, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Personal Rights allegation of staff video recorded minor on a cell phone. The above allegation had preponderance of the evidence to prove that the alleged violation occurred, therefore the findings are substantiated. Report continues LIC-9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 09/01/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
LPA Rosas conducted interviews with clients and facility staff that provided information on how minors in placement receive therapy sessions, provide a supportive environment for minors and facility services. Staff and clients provided statements on how the facility has onsite therapist and clients are encouraged to attend therapy sessions. The facility had provisional Short Term Residential Therapeutic Program (STRTP) and was partner with Ventura County to provide mental health services. The facility provides the residents psychosocial and other alternative treatments such as Art, Equine Therapy, Individual Therapy, and community outings. The staff and clients describe the care and supervision of the facility. LPA Rosas, reviewed facility daily schedule and obtained copy of LIC500 and ratio was in compliance with regulations. LPA Rosas obtained staff training records from Relias. On 08/10/2021 and 07/28/2022, LPA Rosas conducted facility inspection and found facility to be following building and grounds regulations. The facility reported, not having bed bugs and interview confirm the statements. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Neglect/Lack of Supervision, Physical Plant, and Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On September 1, 2022, at 09:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Serenity House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas conducted a facility inspection and conducted interviews. LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated September 1, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegations that facility staff are not trained, Facility is out of ratio, facility is dirty, facility has bed bugs and facility advertising false services. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 09/01/2022

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


raw_content:
Narrative:
During the review of children's records on 08/10/2021, 07/28/2022, LPA Rosas observed client Client#1 (C1), Client#2 (C2), Client#3 (C3) Psychotropic Medication Administration Record (PMAR) the log had errors in who administered the medication. The medication log had missing initials for when the medication was administered. It was unclear whether the clients received their Psychotropic medication. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication violation is substantiated. Based on file review on 08/10/2021, 07/28/2022, LPA Rosas observed client C1, C2, C3 psychotropic Medication Administration Record (PMAR) the log had errors in who administered the medication which poses a potential Health, Safety or Personal Rights risk to residents in care. One deficiency was observed (refer to LIC 809D) and facility is cited for violation of Interim Licensing Standards (ILS), Short Term Residential Therapeutic Program (STRTP) Version 4, Article 6, Continuing Requirements. 87070. Children's Records (12) (H) Staff initials for each time a psychotropic medication is taken by a child, as an indication that they supervised the child self-administering their psychotropic medication. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On September 1, 2022, at 10:00am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Serenity House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas conducted facility inspection and interviews. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated September 1, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Medication allegation of facility staff mismanaged minors' medication. The above allegation had preponderance of the evidence to prove that the alleged violation occurred, therefore the findings are substantiated. Report continues LIC-9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 09/01/2022

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


raw_content:
Investigation Findings:
13On July 2, 2021 at 4:01 pm Out of State Group Home Analyst Sarah Waklee called Kids to Kids Serenity House, Senior Manager to discuss the above allegation. Analyst Waklee made multiple attempts to contact the named youths Social Worker, all of which were unanswered and voicemails unreturned. The named youth is no longer at the facility, therefore Analyst Waklee was unable to interview the youth. Based on confidential interviews with staff, Analys Waklee determined that the allegation is unsubstantiated. An unsubstantiated finding means, although the allegation may have happened, the preponderance of evidence does not prove it. A copy of this report was provided to Kids to Kids Serenity House. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Sarah Waklee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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

met_with: Andrea Espinosa, Senior Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 10/20/2021 at 11:00am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 4 of Staff and 4 of 6 youth files as identified on the LIC 811 confidential names dated October 20th, 2021, were reviewed. 2 of Staff and 1 of 6 youth were also interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to CEO/ Administrator David Yasutake.

report_type: Facility Evaluation

visit_type: Case Management

met_with: CEO/ Administrator David Yasutake


summary: Facility Evaluation

raw_content:
Narrative:
On 11/16/2021, at 8:00am Licensing Program Analyst (LPA) Enrique Hernandez conducted a Case Management - Incident inspection at the above-said facility, and met with the David Yastake Facility Administrator (FA), Danny Bakst (Head of service) and Catherine Tevere Therapist (S1) in response to a Special Incident Report that reported to Community Care Licensing (CCL) on 11/12/2021. The incident, which occurred on 11/12/2021, involved client (C1), who was pronounced dead after attempting suicide at the facility. [See LIC Confidential Names List form (LIC811), dated 11/16/2021, for names]. LPA interviewed Facility Administrator, the Head of Service and the therapist. LPA obtained the following documents: a current staff and client roster, five (5) incident reports (LIC 624) and one (1) Law Enforcement Contact Report (LIC624-LE), Master Treatment Plan, daily log dated 11/12/2021, emails of the request for therapy and psychiatric services to Ventura County Behavioral Health, and the latest Needs and Services Plans for C1. LPA requested a copy of C1's death certificate and the CFT when available and be submitted to the El Segundo Children's Residential Regional Office, as soon as possible. At this time, further investigation is required in order to the determine whether any violation had occurred. 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 4, there are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left with the Facility Administrator (FA).

met_with: Administrator


facility_name: KINFOLKS HELPING HANDS INC

summary: Facility Evaluation

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

visit_type: Prelicensing

met_with: TA Call - Teams


summary: Facility Evaluation

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

met_with: Demitri Roberts, Applicant


facility_name: KOINONIA HOMES FOR TEENS #5

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

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

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

met_with: Bill Ryland, Director


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

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

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

met_with: Patti Ambriz, Facility Administrator


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

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

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


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

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

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

met_with: Patricia Ambriz, FFA Administrator


summary: Facility Evaluation

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


facility_name: KOINONIA HOUSE #1

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

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

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


summary: Complaint Investigation - Substantiated

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

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

met_with: Dareal Morales, Facility Administrator


summary: Complaint Investigation - Unsubstantiated

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

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

met_with: Marsh Hesch, FFA


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

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

met_with: Eddie Sanchez, Administrator


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

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

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

met_with: Eddy Sanchez, Facility Administrator


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

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

met_with: Canaan Sampson, Facilities Supervisor


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

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

met_with: Linda Wagner, Facility Administrator


summary: Facility Evaluation

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

visit_type: Annual

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


summary: Facility Evaluation

raw_content:
Narrative:
On 5/11/22 at 3: PM, Licensing Program Analyst (LPA) Stephanie Lor made an unannounced visit to conduct a case management regarding incidents that were revealed to LPA during a complaint interview. The list of concerns include: -Hygiene products are not being provided to youth -Youth do not have access to personal belongings LPA observed the facility to be clean and in good repair. LPA observed a kitchen with menu posted on the wall, a pool table near the kitchen, and a living room with sufficient furniture. LPA conducted interviews with 2 staff. An exit interview was conducted with Facility Administrator and a copy of this report will be emailed to the facility. This case management investigation needs further investigation.

met_with: Troy Sheridan, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 6/7/22 at 10:37am, Licensing Program Analyst (LPA) Stephanie Lor made an unannounced case management delivery to the above STRTP. LPA met with Administrator. This is a case management report from date 5/11/22. The list of concerns included: -Hygiene products are not being provided to youth -Youth do not have access to personal belongings LPA completed 6 interviews during the investigation process. It was confirmed that youth are receiving hygiene products. In addition, there were inconsistent statements regarding access to personal belongings. This case management will be closed and no deficiencies were cited. An exit interview was conducted with the Administrator and a report will be emailed to the facility.

met_with: Troy Sheridan, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 6/7/22 at 10:37am, Licensing Program Analyst (LPA), Stephanie Lor made an unannounced visit to conduct a case management regarding information revealed to LPA during a complaint interview. LPA met with Administrator. LPA interviewed 4 clients on 5/24/22, it was reported that clients feel uncomfortable at night due to staff supervising by their door and keeping the lights on in the hallway. LPA conducted interviews with 1 staff. Staff reported that the incident is no longer occurring. An exit interview was conducted with 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 10/27/22 at 9:07am, Licensing Program Analysts (LPA) Stephanie Lor made an announced required inspection to the above facility. LPA met with the Administrator and Administrator Assistant. LPA observed all required postings posted. LPA observed and tested smoke detectors and carbon monoxide detectors. There is 1 staff office with locked files, desks, lockers, and extra beddings. LPA observed 2 bedrooms with appropriate bedding and furniture. A Technical Assistant (TA) was given for torn blanket in one of the client's bedrooms. All bathrooms were tested and working. The water tested at the required temperature. The locked hallway cabinet contained extra linens, towels, blankets, cleaning supplies, and hygiene products. All cleaning chemicals were locked and inaccessible to clients. LPA observed medications and sharps to be locked. There were 2 fire extinguishers on site. LPA reviewed 5 staff and 2 youth files, all required documents were observed in the files. First aid kits had all required items. LPA interviewed 2 staff. No clients were available to interview during this inspection. LPA observed the kitchen refrigerator, freezer and pantry to be filled with perishable and non- perishable food items. LPA observed an adequate supply of utensils, dishes and a menu. A trash bin with a lid is located in the kitchen. The living room was observed to have adequate furniture and lamps. A laundry room with a washer and dryer is available to the clients. LPA observed the outdoor area to be clear of clutter and debris. The facility vans contained first aid kits and vehicle logs. The locked garage contained holiday decorations, tools, can goods, and client's inventories. A Technical Violation (TV) was given for window screens. A copy of this report will be emailed to the Administrator.

met_with: Canaan Sampson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tana Kinder and Shalisa Stiger conducted an unannounced inspection with the facility administrator on 11/10/22 at 4pm, related to a complaint in order to conduct interviews. LPAs inspected the facility inside and out. No citations were issued. Further investigation required. An exit interview was conducted and a copy of the report was provided.

met_with: Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/24/23 at 3:30pm, Community Care Licensing Division (CCL) conducted an in-person meeting with Koinonia to discuss some concerns regarding blanket policies in the Program Statement. The meeting was held at Natomas Drive Park, Sacramento, CA 95834. The attendees were as followed: Community Care Licensing Division (CCLD): Regional Manager (RM) Margo Castaneda, Licensed Program Manager (LPM) Rosa Rodriguez, Licensed Program Analyst (LPA) Stephanie Lor Koinonia: Executive Director Tiffany Sickler, Administrator Canaan Sampson, Compliance Manager Laura Richardson, Board Member Krystal Edwards Ombudsman Foster Care Office (OFCO): Manager Brittany Newton, Ombudsman staff Larry Fluharty Child Trafficking Program Unit (CTPU): Associate Government Program Analyst Darrin Holt, Staff Manager Ashley Bray System of Care Branch (SOCB): Manager Marjana Jackson, Help Program Specialist Shamika Payne, Provider Policy Manager Alicia Bernstein During the meeting, the following sections were discussed with Koinonia attendees; Section Transportation, Section Trauma Interventions, Section Complaints and Grievances, Section House rules, Section Nursing and Section Emergency Intervention. Due to the lack of time, not all sections were discussed thoroughly. However, it was agreed upon that there cannot be blanket statements in the Program Statement. () The next step is Koinonia will edit their program statement to reflect the changes and will email it to Licensing Program Analyst (LPA) Stephanie Lor for review by March 24th, 2023. Koinonia attendees were provided with resources for guidance with the Program Statement by all the departments during the meeting. The following email was provided to Koinonia for guidance: csecprogram@dss.ca.gov Exit interview was conducted and a report will be emailed to the facility for signature.

met_with: Koinonia Staff


summary: Facility Evaluation

raw_content:
Narrative:
On 4/25/23, Licensing Program Analyst (LPA) Stephanie Lor conducted a case management at the above facility to follow up on 2 incident report received on 4/17/23 and on 4/13/23 by CCL. LPA interviewed 2 staff during this inspection. This report is created to document this inspection. Further investigation is needed.

met_with: Marsha Hesch, FAA


summary: Facility Evaluation

raw_content:
Narrative:
On 4/28/23, Licensing Program Analyst (LPA) Stephanie Lor delivered a case management inspection regarding an incident report received by CCL on 4/13/23. LPA completed 3 interviews with involved parties. Based on the interviews conducted, the facility followed protocol and the substance was properly disposed. In addition, youth denied having involvement with bringing the substance into the facility. An exit interview was conducted with the FA and a copy of this report was provided to the facility. This case management investigation is closed.

met_with: Eddie Sanchez, FA


summary: Facility Evaluation

raw_content:
Narrative:
On 5/5/23, Licensing Program Analyst (LPA) Stephanie Lor delivered a case management inspection to the above facility regarding an incident received by CCL on 4/12/23 regarding personal rights violation. LPA conducted 3 interviews with the parties involved. Based on the interviews conducted, it was reported that the youth were "playing around." The staff addressed the issue and the youth are no longer sharing rooms together. This case management investigation is closed. An exit interview was conducted with the Administrator and a copy of this report was provided to the facility.

met_with: Eddie Sanchez, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/29/23, Licensing Program Analyst (LPA) Stephanie Lor conducted a case management to discuss an incident that occurred on 8/28/23 regarding the clients in care. LPA conducted interviews with 3 clients and 2 staff. This case management investigation needs further investigation. An exit interview was conducted with the Administrator and a copy of this report will be emailed to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/11/23, Licensing Program Analyst (LPA), Stephanie Lor conducted a case management for an incident that occurred on 8/28/23. This is a continuation of 8/29/23 case management. LPA Lor completed interview with the client who reported that the clients were playing around and that the staff addressed the issue in the home. 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:
Licensing Program Analyst (LPA) Sara Luman-Gonzalez made an unannounced inspection on October 21, 2024 at 8: A.M. During the inspection LPA met with Eduardo Sanchez who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection 2 staff to 0 kids as they were in school. Youths returned from school with 2 more staff. Number of staff interviewed Number of clients interviewed LPA observed 3 bedrooms, 3 bathrooms in the facility. LPA inspected and/or reviewed the following: Physical Plant License, Personal Rights, Emergency ID, and Facility Sketch are all posted with Mental Health Certification in the front of the entryway. Two fridges and freezers were observed to be filled with 5 days of food, with menu posted on the door. Pantry was filled with the 7 days of non-perishable items. Working phone is in the kitchen area and in the office area. Carbon Monoxide Detector and Smoke Detectors were observed to be in working order. First Aid Kit was observed to be fully stocked. Medication was locked in the office. Office is locked while youth are present. Hot water was tested at 107 degrees. Fire Extinguishers were labeled and fully charged. All Bathroom and Bedroom Fixtures were observed to be in good repair, no cracks, holes or chips. Bedroom linens were observed to be clean and one item, new bookshelf, was on order. Laundry facilities with the schedule are available. The rear yard had some debris present (See LIC 9102TV) All exterior facilities were observed to be in compliance. Facility is free of vermin. Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts. (Cont. on 809C Page 1 of 3) Operations Board minutes for 2 quarters reviewed. Complaint procedures were reviewed. All observed to be in compliance. Disaster Preparedness Disaster and mass casualty plan was observed in the entryway. Fire Drills are scheduled for monthly. Earthquake and Flood Drills are ran quarterly. All are documented online for LPA's reviewed. Disaster preparedness supplies verified to be available. Emergency Intervention This facility does not use restraints. Staffing/Volunteers LPA reviewed 7 files. All Criminal Record Clearances are verified. All First Aid/CPR certificates were observed to be current. All Staff files were observed to be compliance. Hours required training verified. Hours required annual training also verified. Client Records LPA reviewed 6 client files. Needs and Services Plans were observed in compliance. Cash log was reviewed and was observed to be in compliance. Medication logs were observed to be in compliance. LPA noted that there were no pronouns on client files. (See LIC TA) Core/Therapeutic Services Trauma Informed Practices are implemented as needed; Such as group therapy and sessions at the home. Equine therapy, Tech group, and healthy relationships are all services that are provided by the agency. (Cont on LIC 809C; Page 2 of 3) The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees · Administrator Certificate for: Eduardo Sanchez · Emergency Disaster Plan (per H&S Code 1565) · Accreditation Name and Expiration Date: October 2025 · Mental Health Program Certificate Expires: October 2025 · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions An exit interview was conducted with Eduardo Sanchez, Facility Administrator and a copy of this report was left at the facility.

met_with: Eduardo Sanchez, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 16, 2025, Licensing Program Analysts (LPA) Sara Luman-Gonzalez and Orlando Areizaga arrived at the above Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management inspection. LPAs' observations are as follows: Upon arrival to the facility, LPAs' observed a natural pond that was not there at the last visit to the facility. LPA was able to observe that the pond was deep enough for large geese and ducks to swim in. -LPA addressed the pond with FA in training who informed that it was a natural, non man-made, pond that occurs throughout heavy rain in the area. LPA brought up the drowning risks. FA in training specified the alarms on the doors and windows alert staff to the unauthorized exit of a youth and they follow to maintain line of sight. Some youths do play in the pond, catching fish and frogs, with supervision. The grass was over grown in part of the front, side, and rear yard where LPA could not see their feet through the overgrowth. - LPA addressed the overgrowth as an issue and reminded that it is a safety hazard. FA in training showed that Lawn care is scheduled to come out to the facility on Fridays'. Also a youth in care volunteers to mow the lawn as it calms them down. Maintenance also stated that they would address this issue. LPA observed at three (3) windows had no screens installed at the time of the visit. - Screens are not damaged, The youth in care remove them and staff 'pop them back in'. LPAs observed expired food in the fridge as well as one (1) damaged can in the pantry area. - FA in training threw way the expired/damaged items. A LIC TV was issued for the CCR, Title 22 80087 (a) Buildings and Grounds. Appeal Rights were discussed and an exit interview was conducted with FA in training. Copy of this report and Appeal Rights were left at the facility.

met_with: Linda Wagner, Facility Administrator in Training


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Misty Valencia on 08/26/2025 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia met with Juan Magallon, Administrator and inspected the facility inside and out. LPA reviewed 0 of 5 child's records and 3 of 3 staff personnel files on site at the facility. Four clients are private placed and one was recently placed 4 days ago. LPA reviewed 0 of 5 child's psychotropic medications and medication records. LPA interviewed 3 of 3 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 of 5 children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Juan Magallon, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Juan Magallon, Administrator.

met_with: Juan Magallon, Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 18, 2025, Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at the above facility for the purpose of conducting a case management inspection regarding medications. LPA was granted entry by Juan Magallon, Facility Administrator in Training. On September 8, 2025, an incident report was submitted to the Department stating a youth was given another youth's medication by mistake. This error was caught by staff after youth had consumed the medication. FA confirmed the incident and the plan of correction implemented by the facility to prevent the error from happening again. Based on interviews conducted and record review, it was confirmed that the incident took place. LPA is issuing a citation for ILS 87075 (c) Health Related Services (See LIC 809D). The facility has already conducted additional trainings with staff on how to properly dispense medications which occurred on 9/9/25 and 9/16/25. LPA Luman-Gonzalez collaborated with FA and Training Coordinator regarding the Plan of Correction and the implementation. An exit interview was conducted with Facility Administrator in Training and a copy of this report and the appeal rights were given to the Facility.

Deficiencies:
87075(c): (c) Psychotropic medications shall be used only in accordance with the written directions of the phsycian prescribing the medication...

title:
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7Health Related Services


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Hillary Hall and Student Assistant (SA) Kate Rosander on 7/28/2022 at 10:30am. During the inspection, LPA Hall met with Administrator Troy Sheridan and inspected the facility inside and out. The facility was clean and organized. During the tour of the facility, LPA Hall observed the medication to be locked in a file cabinet in the locked staff office. LPA reviewed 2 client files on site at the facility. LPA interviewed 2 clients. LPA reviewed 3 staff personnel files LPA interviewed 3 staff on site. LPA completed a medication count. During the review of client records, LPA Hall observed 1 client did not have a current Needs and Service Treatment Plan completed within 30 days of placement. One deficiency was observed (refer to LIC 809D) and cited from the Interim Licensing Standards Section 87068.2: Needs and Services Plan: (a) Social work staff shall obtain the information specified in Section 87070, and shall develop an individual needs and services plan, within 30 days of placement, for the child that meets the requirements specified in (b) through (d) below and includes the anticipated duration of the treatment, and the timeframe and plan for transitioning the child to a less restrictive family environment. LPA conducted an exit interview with Administrator Troy Sheridan LPA provided a signed copy of this LIC-809 to the Administrator upon completion. Appeal rights were provided.


summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2024, at approximately 12: P.M. Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at the facility. LPA was greeted at the door by Staff (S1), Cole Blaufarb and granted entry into the facility. Facility Administrator (FA) was not currently at the facility but arrived 30 minutes later, with youths in care. Upon arrival, LPA met with FA for the purpose of a conducting a Case Management regarding Medications. An incident report was submitted to the Department stating that a Youth in Care received the incorrect dosage of medication from 4/16/24-4/23/24, this was caught by FA and another Staff member on the evening of 4/24/24 and reported to the psychiatrist the following morning. FA confirmed the medication error and the Plan of Correction that was implemented in the facility as of that incident. Based on interview(s) conducted and record review, it was confirmed that the incident took place. LPA is issuing a citation for CCR. 87072 (c)(29) Personal Rights(See LIC 809D). The facility will be conducting additional training with all staff on how to properly dispense medications. FA has it scheduled for Wednesday, May 9, 2024. LPA Luman-Gonzalez collaborated with FA regarding the Plan of Correction and the implementation. An exit interview was conducted with Facility Administrator and a copy of this report and the appeal rights were given to the Facility.

met_with: Facility Administrator, Eddy Sanchez


facility_name: KOINONIA HOUSE #2

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

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

met_with: Jasmine Brown, FFA Admin Assistant


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

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

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


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

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

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

met_with: Administrator, Jazmyn Brown


summary: Complaint Investigation - Substantiated

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

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

met_with: Jazmyn Brown, Acting Facility Adminsitrator


summary: Complaint Investigation - Unsubstantiated - 3 allegations

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

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

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

met_with: Jazmyn Brown, Facility Administrator


summary: Facility Evaluation

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

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


summary: Facility Evaluation

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

met_with: Ashley Young, Administrator


summary: Facility Evaluation

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

met_with: Jazmine Brown, FFA Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/28/22, Licensing Program Analyst (LPA), Stephanie Lor made an unannounced visit to conduct a case management regarding possible personal rights violation. LPA met with the Administrator. LPA conducted interviews with 2 staff. LPA requested for copies of the facility's protocol. Copies will be emailed to LPA Lor. An exit interview was conducted with the Administrator and a copy of this report was provided to the facility. This case management investigation needs further investigation.

met_with: Ashley Young , Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 1/26/23, Licensing Program Analyst (LPA) Stephanie Lor concluded a case management from 12/28/22 regarding personal rights. It was determined that the facility was following their protocol regarding sick youth and clothing expectation. This case management will be closed. No defienceies cited. An exit interview was conducted with the Administrator and a copy of this report was provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Luman-Gonzalez & Areizaga made an unannounced inspection on 11/18/2024 at 9: A.M. During the inspection LPA met with Jazmyn Brown, Facility Administrator who assisted with the inspection. LPAs conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection Staff Members and Clients. Staff were interviewed; Client was interviewed. LPA observed 3 bedrooms and 3 bathrooms in the main house. The rear structure held a large living area with a kitchen for staff and another bathroom and 2 offices. LPAs inspected and/or reviewed the following: Physical Plant All documentation including Personal Rights, Grievance Policies, and Facility Sketch are posted at the front of the house. The kitchen area houses sharps in a locked drawer and was observed to be clean. The fridge and freezer housed at least 7 days worth of food. The pantry housed at least 7 days of nonperishable foods. The freezer was 5 degrees below 0 with the fridge at 30 degrees. Menu and alternatives were present and posted on the fridge wall. Working telephone is in the office area and another is on the desk in the living room area. Smoke Detectors were observed to be in working order. First aid kit was fully stocked. Disinfectants and Cleaning Solutions were behind locked cabinets in the hallway. There are multiple common rooms available for the youths to occupy. Medications are stored in the staff office behind a locked door and in a locked cabinet.Hot Water between 105-120 degree F. Fire extinguishers were observed to be charged. Toilets wash basin, bath and shower fixtures in good repair/no leaks. Soap and Paper towels were observed in the bathroom area. Laundry Facilities are in the hallway with a schedule of which days which youth and do their laundry. Bedrooms had appropriate furnishings and clean linen. Extra linens were stored in the hall. Facility Motor Vehicle properly maintained with lights, tires, registration/insurance and working seat belts. Facility is free of vermin. Locked Facilities in the rear yard include the counseling office and 2 garden sheds, all met requirements. Operations Complaint Procedures for Youth were reviewed. The previous 2 quarters of board minutes were also reviewed by LPA. Disaster Preparedness Disaster and mass casualty plan updated and available at the front of the facility. Quarterly Drills conducted and documented in the staff office. Disaster preparedness supplies verified. Staffing/Volunteers Number of Staff files reviewed 6. Criminal record clearances were verified along with First Aid and CPR. Job Titles and qualifications were verified along with Training Hours. Client Records Number of Clients files reviewed 5. Needs and Services Plan did not address money management. Centrally Stored Medication log and Medication Administration log was reviewed and verified. Signatures were missing from forms (See LIC TV) referring to Cash Resources amongst them. Core/Therapeutic Services Trauma Informed Practices are implemented as needed and other modes of therapy are used such as Equine Therapy and Healthy Relationships counseling. The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees · Administrator Certificate for: Jazmyn Brown · Emergency Disaster Plan (per H&S Code 1565) · Accreditation Name and Expiration Date: October 2025 · Mental Health Program Certificate Expires: October 2025 · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions An exit interview was conducted with Jazmyn Brown, Facility Administrator and a copy of this report and appeal rights was left at the facility.