summary: Facility Evaluation

raw_content:
Narrative:
On September 20, 2022, at 1: PM., Licensing Program Analyst (LPA), Kuliema Calloway, arrived to conduct a Plan of Correction (POC) follow-up inspection in order to see if the deficiencies cited on 8/25/2022 were corrected. There are three clients in care and five staff members. LPA observed the carpet in Bedrooms #1 and #2 were in still in disrepair. In Bedroom #3, the ceiling fan and the ceiling need cleaning. In Bedroom #1 and Bedroom #2, the stains on the wall were still visible. Bedroom #1 and Bedroom #2 were not painted as previously advised. Bedrooms #1, #2, and #3 had clothes in the middle of the room and floor. The outside vent still was not closed off. LPA took photos. There was a POC due date of 9/15/2022 which was not met. LPA asked licensee about the reason for not correcting the deficiency and the licensee stated, "There was a COVID outbreak in the facility on 9/5/2022 and a handyman could not come on site to do the painting during that time. We are currently prepping to paint which is why everything is in the middle of the floor. I got in touch with a local carpet cleaning and repair place on 8/25/22 and as of now there isn't an appointment set for them to come out and it is the only company so far that I have contacted. It should take us at least two days to finish painting. The repair man was on vacation and will be out to seal the outside vent this week. The original request was made on 6/30/2022.." LPA obtained a copy of the repair request list. The facility was given another POC due date of 10/10/2022. Exit interview was conducted. A copy of this report were left at the facility with FA.

met_with: Madison Penningon, Facility Manager


state: CA

facility_name: KIDS TO KIDS - SERENITY HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2022, at 10: AM., Licensing Program Analyst (LPA), Kuliema Calloway, arrived to conduct a Plan of Correction (POC) follow-up inspection in order to see if the deficiencies cited on 8/25/2022 were corrected. LPA was greeted by S1. Client C4 is in care with Staff member, S1, and FA. [See LIC 811- Confidential Names List dated 10/10/2022]. LPA observed the carpet in Bedrooms #1 and #2 has been cleaned. In Bedroom #3, the ceiling fan and the ceiling has been cleaned. In Bedroom #1 and Bedroom #2, the walls were painted. Bedroom #1 and Bedroom #2 were painted as previously advised. The outside vent was closed off. LPA took photos. Therefore, the POC due date of 10/10/2022 was met. Exit interview was conducted. A copy of this report were left at the facility with FA.

report_type: Facility Evaluation

met_with: David Yasutake, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 9, 2023, at 12: PM, Licensing Program Analysts (LPAs), Olivia Rosas and Christine Wilson made an unannounced visit to Kids to Kids- Faith House Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting an Annual inspection. LPA Rosas and Wilson met with Staff#1(S1) who granted access to the facility and an inspection of the facility was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 03/09/2023. LPAs met with Staff#1 (S1), who granted access into the home, and who provided a tour of the entire physical plant. This facility has a provisional Short Term Residential Therapeutic Program (STRTP) license to provide care and supervision for six (6) female children ages 13-17 years old, Ambulatory only. There is no pool or bodies of water on the premises. The facility currently pending Accreditation with CARF International. The facility is in the process of obtaining a Mental Health Program Approval contract with the Department of Health Care Services and Ventura County. Staff confirmed that there are no firearms or dangerous weapons in the facility. The facility is current with their annual fees. LPA Rosas inspected the following: This is a one (1) story (STRP) Short Term Residential Therapeutic Program, located in a residential neighborhood. This is a three (3) three-bedroom, two (2) bathrooms, one (1) staff office in single story family residence that includes a living room, dining area, kitchen, backyard, and an attached garage used for storage. There are two (2) facility vehicles parked outside inspected to be in good operating condition. Outdoor Area: There was no swimming pool or bodies of water on the premises. The activity space is free of hazard materials and debris. LPA observed a staff displayed the utility shut-off valves. The facility is surrounded by brick fence and wire fence is observed to be good condition. The passageways and porches are unobstructed. Report continues on LIC 809-C Page 1 of LPA Rosas reviewed following during the inspection: LPA Rosas requested the following forms for review, Register of Youth (LIC 9020), Current Census, Personnel Report (LIC 500), Emergency Disaster Plan (LIC610C), Emergency Intervention Plan, vehicles registration and auto insurance. In addition, written menus, staff weekly and schedule. Staff Records Review: LPA ensured Administrator Certificate was current. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the three (3) clients in placement. LPA confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response, which meet qualification. LPA Rosas was not able to complete staff file, client file review,and staff interviews and will need to return to facility to complete the staff file review. A review of Facility's Personnel Report Summary on 03/07/2023 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. 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. Laundry Area: The washer and dryer units are located next to the kitchen. The laundry is equipped with a washer and dryer unit that was observed to be in good condition. The laundry detergent is made inaccessible to the children and is disputed according to the load of the laundry. Disinfectants and chemicals are locked and made inaccessible to clients in the staff office. Dining Area/Kitchen: There is adequate furniture which appears to be in good condition. The living room has dining table and televisions. The facility has one living room areas used for recreating and activity room, which provide the necessary space and/or separation to promote and facilitate the program of planned activities and to prevent such activities from interfering with other functions. The living area has game board games, books, DVDs, magazines and art supplies. Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a dishwasher, microwave, refrigerator with freezer and a toaster oven. LPAs observed adequate perishable/nonperishable food supplies. The facility supplies a staple nonperishable food for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. Sharp knives, disinfectants/cleaning solutions made inaccessible to the youth locked in the staff office. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Staff Office: The office is equipped office furniture (i.e desk, computers, printers). Medication is kept locked inside of the staff office. The client and staff files are kept in a locked in file cabinet. LPA observed a key locked closet that stored hygiene supplies, cleaning solutions, and medication. Additional disinfectants, chemicals, hygiene supplies and medication are locked in storage closet in the living room making inaccessible. The office has additional a deep freezer for food. LPA observed overstock of nonperishable food, frozen food, snacks, and supplies. Bedroom # 1: Currently occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Report continues on LIC 809-C Page 2 of Bedroom # 2: Currently occupied by one (1) client, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 3: Is vacant. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting, and the windows have horizontal slide locked with curtains observed to be in good condition. Bathrooms: There are two (2) bathrooms. Bathroom #1 is a full-sized bathroom with a toilet, sink, and shower. Bathroom #2 is full-sized bathroom with a toilet, sink, and shower. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Garage: The garage is kept locked and only staff uses has access to the garage. The attached two car garage is used as storage and is kept locked. The garage has additional fridge and deep freezer for food. LPA observed overstock of supplies. There are two (2) vehicles available to transport youths; make and model are a Honda 2006, and Chevrolet Tahoe. The vehicles used to transport clients appeared to be in a safe operating condition. The registration of the vehicles was valid. The vehicle has full coverage auto insurance with HUB International Insurance Services Inc. During the facility was inspected, the following was observed: LPA observed a key locked closet that stored hygiene supplies, and cleaning solutions. All windows were in good condition with screens and blinds. There were no security bars on the windows. There are two (2) fire extinguishers and was fully charged and carbon monoxide detectors were working properly in the facility. LPA observed ample towels and linen closet. LPA observed several First Aid Kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and a 1st Aid Manual in the staff office, medication cabinet, and garage. All posting requirements were met (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The Emergency Evacuation Plan is posted). The home has a working telephone and youths can use the telephone unless restricted by court order. The living room and staff office is utilized for clients to make phones calls and the Phone Call Log is kept near the facility phone. The youth reported having their own cell phone to be able to make phone calls. Report continues on LIC 809-C Page 3 of 4

visit_type: Annual

met_with: Staff#1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On 12/8/2023, at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management - Incident inspection at KIDS TO KIDS - SERENITY HOUSE and met with Madison Pennington, Facility Manager, in response to a Special Incident Report submitted to Community Care Licensing (CCL) on 12/6/2023. The incident, reports in part that a youth in care was hospitalized due to an overdose. During this inspection, LPA Martin informed the incident has been referred to CCL Investigations Branch, Investigator Peter Zertuche. Upon completion of the investigation, the investigation findings will be delivered. LPA Martin requested and/or obtained the following documents Client file: Client Roster, Personnel Report (Schedule) LIC500, Client Needs and Services Plan (obtained during visit). CFT information, Intake packet and all incident reports for subject client please submit requested documents to LPA Regina Martin at regina.martin@dss.ca.gov The incident requires further investigation. Upon completion, the Department's findings will be issued and discussed. There are no deficiencies cited per California Code of Regulations, at this time.

visit_type: Case Management

met_with: Madison Pennington, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/20/2023 at 10: Licensing Program Analyst (LPA) Jhane Haynes, initiated a case management inspection at the above-said facility and met with Direct Care Staff(DCS) Venessa Duarte, in response to a Special Incident Report that was reported to Community Care Licensing (CCL) on 12/19/2023. The purpose of this inspection is to inform the facility that an investigation is being conducted regarding a possible Neglect/Lack of Supervision violation, involving the death of client (C1) on 12/13/2023, after C1 had been hospitalized due to a drug overdose, from 12/03/2023 to 12/13/2023. After conducting a quick walk-through of the facility, LPA acquired a current staff and client roster. LPA requested a copy of C1's death certificate, as well as a completed Death Report (LIC624A form) be submitted to Community Care Licensing, as soon as possible. C1's bed was closed prior to death, facility has not received death certificate due to client not in facility care at time of passing. Facility will attempt to retrieve death certificate and will email to LPA if released. LPA collected information of C1's social worker. Further investigation is required in order to resolve the investigation. There are no deficiencies to be cited at the time of this inspection. Exit interview conducted, and a copy of this report was left at the facility.

met_with: Venessa Duarte (DCS)


summary: Facility Evaluation

raw_content:
Narrative:
On 05/31/24 at 09:50AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting a case management inspection to ensure location is not in operation. LPA spoke with A1 and S1 who confirmed home was vacant. No deficiencies will be cited today. An exit interview was conducted, and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On August 25, 2022, at 12:30 p.m., Licensing Program Analyst (LPA), Kuliema Calloway, and Licensing Program Manager (LPM), Kevin Sauk, conducted an unannounced Case Management Deficiency Inspection at Kids to Kids Serenity House located at the above address. David Yasutake, Facility Administrator (FA), granted access into the facility and together conducted a tour of the entire facility, inside and out. The purpose of this inspection is to document deficiencies that were observed, on 06/30/2022, during the Post-Licensing inspection. On 06/30/2022, LPA and LPM observed 16 out of 24 staff members (S1 through S16) from the LIC-500 provided to licensing staff that did not have criminal background clearance. (See confidential name list LIC-811 dated 08/25/2022). On 8/25/2022, LPA and LPM observed the following items: An outside vent cover is ripped that allows access underneath the house. The carpet in two of the bedrooms was ripped and in disrepair. The walls have stains and need painting. Board Member's wife, (PJ) came into the facility to cook with the staff and was not fingerprint cleared to be in the facility. The following deficiencies were observed, and cited. (See LIC 809-D) Exit interview was conducted and a copy of this report was left with Madison Pennington, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On 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 to conduct a Case Management-Other (Medication) inspection. During the inspection, LPA Rosas met with Staff#1 (S1) and inspected the psychotropic medication. LPA reviewed two (2) client records on site at the facility. During the review of clients records, LPA Rosas observed 1 out of 2 clients (Client #1) taking Psychotropic Medication did not have a current JV 223. Facility stated, C1 arrived to the facility with expired JV 223 and they are currently waiting updated one from County of placement. The updated JV 223 was submitted to County of Placement on August 18, 2022. Based on record review on 09/01/2022, LPA Rosas observed C1 did not have a current JV 223 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. Children's Records 87070(b)(11) A copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication. Exit interview was conducted with S1 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On January 8, 2023 at 10: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an announced case management other visit at Kids to Kids - Serenity House. During today's inspection, AGPA Woodard conducted a tour of the facility with Vanessa Bracamontes, and the following deficiencies were observed (see LIC 809D). Plan of corrections were discussed with staff and a copy of this report was left.

met_with: Geniveve Heikes


summary: Facility Evaluation

raw_content:
Narrative:
On 02/14/24 at 11: AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of following up on incident reports. It was discovered the department had not received incident reports from the facility. Per California Code Regulation Title 22, Division 6, Chapter 1, one deficiency will be cited today. See LIC809-D for details. An exit interview was conducted and a copy of this report was left at the facility.

met_with: Madison Pennington Facility Manager(FM)


summary: Facility Evaluation

raw_content:
Narrative:
On October 16, 2024, at 11:30 am, Licensing Program Analyst (LPA) Nestor Gomez and Licensing Program Manager (LPM) Kevin Sauk conducted an unannounced inspection of the above said facility and met with Facility Manager (FM), who granted access into the facility. During a complaint investigation, licensing staff observed deficiencies during the walk-through of this facility that was conducted on 10/16/2024 at 9:45am. Licensing staff observed two trash cans in the kitchen, and one trash can in one of the bathrooms, without lids. Licensing staff also observed an outdated menu that was posted on the kitchen refrigerator with a date range of 10/07/2024 to 10/13/2024. The following deficiencies were observed and cited, at the time of this inspection. See attached LIC809-D for deficiencies. Exit Interview was conducted and a copy of this report will be emailed to the FM and the Facility Administrator (FA).

met_with: Facility Manager (FM)


facility_name: KOA HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

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

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

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

report_type: Complaint Investigation

met_with: Jesse Lozano

complaint_status: unsubstantiated


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

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

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


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

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

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


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

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

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

met_with: Richard Perreno


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

Investigation Findings:
13On 02/23/2023 at 10: AM, Licensing Program Analyst (LPA) Joon Choi made an unannounced visit to deliver the investigative findings for the allegation listed above and met with Koa Home Group Home (GH) Administrator Fernando Melendez. On 03/15/2022, LPA Linda Haynes conducted an initial health and safety inspection of the facility. No immediate health and safety hazards were observed. On 02/07/2023, LPA Choi conducted a follow-up visit to the facility, and no immediate health and safety hazards were observed. LPA Haynes interviewed the House Manager (S1), and LPA Choi interviewed the Administrator (S2) and three Direct Care Staff (S3, S4, and S5). LPA attempted to interview Client 1 (C1) but could not be interviewed due to the inability to communicate verbally. On 03/09/2022, Community Care Licensing received an allegation that minor sustained unexplained injuries while in care. Confidential interviews reported that two fresh, small cuts (the size of an adult's pinky nail) were observed on the right side of Client 1's (C1) face. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/23/2023

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

met_with: Fernando Melendez, Administrator


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

Investigation Findings:
13On 02/23/2023 at 09: AM, Licensing Program Analyst (LPA) Joon Choi made an unannounced visit to deliver the investigative findings for the allegation listed above and met with Koa Home Group Home (GH) Administrator Fernando Melendez. On 04/26/2022, LPA Linda Haynes conducted an initial health and safety inspection of the facility. No immediate health and safety hazards were observed. On 02/07/2023, LPA Choi conducted a follow-up visit to the facility, and no immediate health and safety hazards were observed. LPA Haynes interviewed the Clinical Director (S1), and LPA Choi interviewed the Administrator (S2) and three Direct Care Staff (S3, S4, and S5). LPA attempted to interview Client 1 (C1) but could not be interviewed due to the inability to communicate verbally. On 04/21/2022, Community Care Licensing received an allegation that a staff member (S4) handled the minor (C1) in a physically aggressive manner. Confidential interviews reported that when C1's school bus arrived at the facility, C1 saw a facility staff member (S4 and S5) approach the bus, at which point C1 became agitated. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/23/2023

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

met_with: Fernando Melendez, Adminstrator


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

Investigation Findings:
13On 02/23/2023 at 09: AM Licensing Program Analyst (LPA) Joon Choi made an unannounced visit to deliver the investigative findings for the allegation listed above and met with Koa Home Group Home (GH) Administrator Fernando Melendez. On 05/10/2022, LPA Linda Haynes conducted an initial health and safety inspection of the facility. No immediate health and safety hazards were observed. On 02/07/2023, LPA Choi conducted a follow-up visit to the facility, and no immediate health and safety hazards were observed. LPA Haynes interviewed the Clinical Director (S1), and LPA Choi interviewed the Administrator (S2) and three Direct Care Staff (S3, S4, and S5). LPA attempted to interview Client 1 (C1) but could not be interviewed due to the inability to communicate verbally. On 05/06/2022, Community Care Licensing received an allegation that the child (C1) sustained unexplained injuries while in care. Confidential interviews reported that C1 had a scratch and a bruise on their left eye about an inch long, three bruises on C1's forehead about two inches long, and the color was reddish-brown. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/23/2023

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


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

Investigation Findings:
13On September 28, 2023, at 2: PM Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with facility staff, Fernando Melendez, to issue the finding for the above stated allegation. The complaint investigation was jointly conducted by LPA J. Choi, LPA L. Haynes, and LPA M. Almaraz. On September 20, 2022, at 2: PM, LPA Choi arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA Choi also reviewed one client's (C1) records see confidential names list (LIC 811) dated September 28, 2023. Additionally, LPA Almaraz conducted interviews with four staff, a county social worker (CSW), three confidential witnesses, and four of four clients. LPA didn't receive responses from three of four clients due to being non-verbal. On September 12, 2022, the Department received a complaint that alleged a minor sustained a bruise while in care. More specifically, it was alleged that due to lack of supervision C1 had a bruise on C1's back on September 8, 2022. During the course of the investigation, confidential witnesses stated that C1 tends to have tantrums where C1 will roll on the ground. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 09/28/2023

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

met_with: Fernando Melendez


raw_content:
Narrative:
Based on inconsistent confidential interviews, the allegations that the minor (C1) was roughly handled (grabbed and dragged) at the facility, the facility staff made an inappropriate/threatening comment to C1 and facility staff does not provide assistance to C1 when getting off the bus may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report and LIC 811 was provided to Irma Holguin, Direct Staff Personnel. A confidential interview stated they witnessed two staff grabbing C1 by the feet and dragging C1 into the room. Other confidential interviews stated that the staff at the facility did not grab and drag C1 into the room and it is not the standard of care at the facility. Confidential interviews stated that C1 drops to the ground often when C1 is having behavior issues and C1 will stay on the ground banging the head to the ground or swinging the arms and grabbing a hold of someone that's standing close by and bite their ankles. Additionally, the confidential interviews stated when C1 drops to the ground, the staff would have to lift C1 off the ground and carry C1 into the facility sometimes with force and it is the only way to handle C1 due to the behavior issues; and in the eyes of bystanders may look like the staff is grabbing and dragging C1 into the room. Community Care Licensing also received an allegation stating that the facility staff made an inappropriate/threatening comment to minor. Specifically, it was reported that a staff was heard saying to C1, "I guess you don't want to eat today.". A confidential interview stated they heard a staff denying food to C1 because C1 was having behavior issues and did not want to get up from the ground. Other confidential interviews stated that the staff would never make inappropriate or threatening comments to minor at the facility. Additionally, the staff do not use food as a source of punishment or reinforcement. Furthermore, C1 is healthy and has been gaining weight since placement and there is no concerns of the staff at the facility. Community Care Licensing also received an allegation stating that the facility staff does not provide assistance to minor (C1) when getting off the bus. Specifically, it was reported that the staff does not pick up C1 from the bus and the school aide had to physically take C1 to the facility due to C1 refuses to get off the bus. A confidential interview stated the facility staff should pick up C1 from the school bus door due to liability issues. Another confidential interview stated it is the responsibility of the school district staff to assist C1 off the school bus and use the walker to get from the school bus to the front door of the facility and one of the facility staff will assist C1 into the facility. Additionally, a confidential interview stated due to the safety of C1 and to prevent C1 from dropping on the ground due to behavior issues, it was agreed the school district staff was to drop C1 off at the facility door. *continued on LIC 9099c*

Investigation Findings:
13On 10/10/2023 at 2:03pm, Licensing Program Analyst (LPA) Sarah Lo met with Irma Holguin, Direct Staff Personnel, to deliver the findings for the above complaint allegations at Koa Home Group Home (GH). On 10/18/2022 at 09: AM, LPA Haynes inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with two staff [Staff #1 (S1) and Staff #2 (S2)], one client (C1), County Social Workers (CSW), Case Worker (CW), and four school district staff [School District Staff #1 (SD1), School District Staff #2 (SD2), School District Staff #3 (SD3) and School District Staff #4 (SD4)]. Needs and Services Plans and case notes were reviewed. On October 12, 2022, Community Care Licensing received an allegation that the minor (C1) was roughly handled (grabbed and dragged) at the facility. Specifically, it was reported that C1 was dropped off to the facility after school and dropped to the ground and a staff grabbed C1 by the feet and dragged C1 into the room. **continued on LIC 9099c** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 10/10/2023

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

met_with: Irma Holguin, Direct Staff Personnel.


raw_content:
Narrative:
Regarding the allegation that C1's hair was not groomed appropriately. Confidential witnesses stated staff assisted C1 with grooming C1's hair. Confidential witnesses added that staff ensured all clients were groomed appropriately. CSW4 informed LPA that she had never observed any clients to not be groomed appropriately. Other confidential witnesses stated that they had observed C1 with her hair not groomed appropriately on several occasions. Concerning the allegation that staff did not provide C1 with feminine products. Confidential witnesses stated that facility staff had always provided C1 and the other clients with all their hygiene products. CSW4 had no concerns that the facility staff was not ensuring that clients had the hygiene products that they needed. LPA received other information that C1 did not have feminine hygiene products provided to C1 by facility staff. With regard to the allegation that facility staff did not communicate C1's medication needs to C1's school. Confidential witnesses stated that facility staff did communicate with C1's school. CSW4 stated that there was good communication between client's schools and the facility. LPA received other information that the facility was not ensuring that C1's school was aware of C1's medication and mental health needs. Based on confidential interviews and record review, the allegations that C1's hair was not groomed appropriately, staff did not ensure that C1 had feminine hygiene products, and staff did not communicate with C1's school regarding C1's medication may have occurred, however, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Yusif Rizk.

Investigation Findings:
13On February 29, 2024, at 2: PM Licensing Program Analyst (LPA) Michael Almaraz met with facility Direct Service Professional, Yusif Rizk, to deliver the finding for the above allegations involving client #1 (C1) listed on the confidential names list (LIC 811) dated February 29, 2024. On September 25, 2023, at 12: PM LPA inspected the facility. During LPA inspection LPA reviewed one client's records, conducted one staff and one client interview. Additionally, LPA Almaraz conducted interviews with three staff members, one county social worker (CSW4), two confidential witnesses, and three of four clients. On September 15, 2023, the Department received a complaint alleging staff do not ensure that child's grooming needs are met, staff does not provide minor feminine hygiene products, and staff do not communicate with minor's school regarding mental health needs. It was specifically reported that staff did not ensure that C1's hair was groomed appropriately, staff did not ensure that C1 had feminine hygiene products, and staff did not communicate with C1's school regarding C1's medication. (Continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 02/29/2024

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

met_with: Yusif Rizk


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

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

met_with: Fausto Reyes


raw_content:
Narrative:
Based on confidential interviews and record reviews, the allegation that C1 sustained unexplained black eye, may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to House Manager Fernando Melendez

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:
Based on confidential interviews and record reviews, the allegation that staff did not provide adequate supervision to C1 in care, may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to House Manager Fernando Melendez

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:
Based on confidential interviews and record reviews, the allegation that facility staff does not ensure that C1 has appropriate clothing, may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to House Manager Fernando Melendez.

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 allegation that staff sent youth to school with wet under garments specifically refers to C1 arriving to school with wet under garments. Confidential interviews revealed that the staff would always change C1 before the school bus would pick up C1. Other information obtained stated the allegation occurred. The allegation that staff does not effectively communicate with youth's school specifically refers to staff not sending notes to the school with an explanation as to how C1 got hurt. Confidential interviews revealed that the HM calls the school and has meetings with school staff and the school district. Other information obtained stated the allegation occurred. Based on confidential interviews and record reviews, the allegation that C1 sustained an unexplained injury while in care, staff sent C1 to school with wet under garments, and staff does not effectively communicate with C1's school, may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to House Manager Fernando Melendez

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 allegation that staff did not meet minor's medical needs specifically refers to C1 stating that it hurts and burns when using the restroom. Confidential interviews revealed that the staff were not informed that when C1 used the restroom that it hurt and burned. Confidential interviews further revealed that when C1 needed to see a doctor the staff would make sure that C1 was taken to see a doctor. Other information obtained stated that they did not know if the group home knew that when C1 used the restroom that it hurt and burned. Based on confidential interviews and record reviews, the allegation that C1 sustained unexplained injuries while in care and staff did not meet C1's medical needs, may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to House Manager Fernando Melendez

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:
Based on confidential interviews and record reviews, the allegation that staff did not ensure that C1 did not have access to a dangerous object while in care, may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to House Manager Fernando Melendez

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:


summary: Facility Evaluation

raw_content:
Narrative:
On Friday September 24, 2021 at 10: AM Licensing Program Analyst (LPA) Linda Haynes and LPA Lisi Leon conducted an annual inspection of the facility. At time of inspection LPA met with Direct care staff Andrea Bonilla. The facility was toured inside and out with Direct Care Staff Andrea Bonilla. The home is a one-story residence with four bedrooms and three bathrooms. One client was present at time of inspection. Bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the Staff Office. Cleansers/chemicals are locked and stored in closet in hallway above Washing Machine. Sharp knives are inaccessible and stored in a locked cabinet in the Kitchen. The First Aid Kit is located in the staff office and contained all required supplies. The facility's smoke detectors in each bedroom were checked and were inoperable. The carbon monoxide detector located in living room and was inoperable. There are no guns or weapons in the facility as stated by Direct Care Staff Andrea Bonilla. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Visitation policies, and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Four of four client files were reviewed during the inspection and noted to have documents required per regulations in file. Four of four clients are non-verbal and therefore could not be interviewed. Based on the facility inspection and file reviews this date, there are two deficiencies being cited at this time. This inspection was not able to be completed on this day. LPA will return to complete day two of the annual inspection at a later date. A copy of this report and appeal rights was reviewed and given to Direct Care Staff, Michael Covarrubias.

met_with: Andrea Bonilla


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday October 07, 2021 at 09: AM Licensing Program Analyst (LPA) Linda Haynes Conducted day two if the annual inspection of the facility. At time of inspection LPA met with facility administrator Samee Arastu. The facility was toured inside and out with facility administrator, Samee Arastu. The home is a one-story residence with four bedrooms and three bathrooms. There were no clients present at time of inspection. Bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom number one was measured to be 119.3 degrees and in client bathroom number two 114.3 degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the staff office. Cleansers/chemicals are locked and stored in cabinet in the hallway above the washer and dryer. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in the staff office and contained all required supplies. The facility's smoke detectors in each bedroom were checked and were operable. The carbon monoxide detector is located in the kitchen and was operable. There are no guns or weapons in the facility as stated by facility administrator Samee Arastu. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Visitation policies, and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. () A sample of client and staff files were reviewed during the inspection and noted to have documents required per regulations in file. No clients were interviewd as no one was home at time of inspection. All clients are also nonverbal and can therefore note be interviewed. All staff that work at the facility have Department of Justice, FBI and Child Abuse Index clearances. Based on the facility inspection and file reviews this date, there are no deficiencies found at this time. A copy of this report was reviewed and given to facility administrator Samee Arastu.

met_with: Samee Arastu


summary: Facility Evaluation

raw_content:
Narrative:
On June 10, 2022 at 1030AM, Licensing Program Analyst (LPA) Val Wilson, arrived Koa Home Group Home (GH) for an unannounced SB Psychotropic Medication Inspection. The purpose of the inspection was to complete the continuation SB 484 inspection that was initiated on May 12, 2022. The LPA was met by Samee Arastu, PsyD, Clinical Director/Administrator, and Fernando Melendez, House Manager. During this SB 484 inspection continuation: LPA reviewed Policy and Procedure and Program Design. LPA reviewed four of four client (Client 1- C1; Client 2- C2; Client 3- C3; Client 4- C4) Needs and Services Plans to ensure they contained all required documentation. During the review of children's records, LPA Wilson observed 4 out of 4 children now have a separate log for each psychotropic medication prescribed with the date and time of each dose taken by the child. LPA conducted exit interview with Samee Arastu, at 12:20PM. LPA provided the Summary Report to Samee Arastu upon completion.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/02/22 at 09:05 am, Licensing Program Analyst (LPA) Sarah Lo arrived at Koa Group Home (GH). LPA Lo was met and granted access by House Manager (HM), Fernando Meledez. The purpose of the visit is to conduct an annual inspection of the facility. At the time of inspection LPA met with HM Meledez and was given a tour inside and out. The home is a one-story residence with four bedrooms and three bathrooms. One client was present at time of inspection. At 09:10 am, LPA started the Physical Plant and bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the Staff Office. Cleansers/chemicals are locked and stored in closet in hallway above the washing machine. Sharp knives are inaccessible and stored in a locked cabinet in the Kitchen. The First Aid Kit is located in the staff office and contained all required supplies. The facility's smoke detectors in each bedroom were checked and were inoperable. The carbon monoxide detector located in living room and was inoperable. There are no guns or weapons in the facility as stated by HM Meledez. LPA observed a minimum 7-day non-perishable and a 3-day perishable supply of food. There was a variety of snacks available for clients as well. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Visitation policies, and current menu. Emergency exits were free from obstruction. At 09:22 am, LPA observed four holes in the walls in the living room. Per ILS 84487(f) The facility shall be clean, safe, sanitary, and in good repair at all times. HM Meledez stated there was an incident that happened last night with a client. HM Meledez stated a maintenance order has been sent out and will be here to fix in two days. Continue of LIC 809-C There is fully fenced backyard with adequate outdoor activity space, free of clutter or debris and well maintained. The outdoor area included a patio set with seating areas for clients to enjoy and relax and a trampoline on the grass area. At 09:30 am, LPA observed a rip on the surface of the trampoline. Per CCR 84087.2(a) Children shall have access to safe outdoor activity space. HM Meledez stated the neighbor's cat teared the trampoline surface. HM Meledez stated will have his worker take apart the trampoline. The trampoline was disassembled by 10:05am. Five of five staff files were reviewed during the inspection and noted to have documents required per regulations in file. Staff interviews were completed with the two staffs that were available at the time. Four of four client files were reviewed during the inspection and noted to have documents required per regulations in file. Four of four clients are non-verbal and therefore could not be interviewed. There was no deficiency cited for Operational Requirement, Disaster Preparedness, Emergency Intervention Plan, Staffing Records, Client Records, Core/Therapeutic Services and Client with Special Health Care Needs. An exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to House Manager, Fernando Meledez.

met_with: Fernando Melendz, House Manager


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday November 21, 2023, at 11: AM Licensing Program Analyst (LPA) Linda Haynes conducted day one of an annual inspection of the facility. At time of inspection LPA met with House Manager (HM) Fernando Melendz. The facility was toured inside and out with HM. The home is a one story residence with four bedrooms and three bathrooms. Bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. Hot water in bathroom number one measured to be 108.6, bathroom number two 105.4 and bathroom number 3 105.8. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications are stored in a locked cabinet in the office. Cleansers/chemicals are stored in a locked cabinet above the washing machine. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in the office and contained all required supplies. The facility's smoke detectors / Carbon Monoxide detectors in each bedroom were checked and were operable. There are no guns or weapons in the facility as stated by HM. The following required posted items was accessible to clients: Grievance Procedures, Personal Rights, and Visitation policies. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is no pool or other body of water. A technical Advisory will be issued for the following. The oven was broken a new one has been ordered. There was one window that was broken it has been ordered and covered with plywood for a temporary fix. The fire extinguisher needs to be replaced a new one has been ordered and will be picked up today. Exit interview conducted and a copy of this report and appeal rights was discussed and provided to HM on this date.

met_with: Fernando Melendz


summary: Facility Evaluation

raw_content:
Narrative:
On November 16, 2023 at 12: PM, Licensing Program Analyst (LPA) Linda Haynes began day two of an annual inspection for Koa Group Home. LPA met with House Manager Fernando Melendz. There were two clients present at time of inspection. LPA reviewed four of four client files all required documents where present. LPA was unable to interview clients as clients are non verbal and unable to answer interview questions. LPA interviewed three staff members that were present at time of inspection. LPA was unable to review client files as the staff present do not have the keys to access the locked files at this time. An exit interview was conducted. A copy of this report and appeal rights was provided to House Manager Fernando Melendz. LPA will return for a day three inspection to review staff files.


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2023 at 9: AM, Licensing Program Analyst (LPA) Linda Haynes began day three of an annual inspection for Koa Group Home. LPA met with House Manager Fernando Melendz. There were no clients present at time of inspection. LPA reviewed 11 of 11 staff files all required documents where present. An exit interview was conducted. A copy of this report and appeal rights was provided to House Manager Fernando Melendz.


summary: Facility Evaluation

raw_content:
Narrative:
On September 13, 2024 at 8: AM, Licensing Program Analyst (LPA) Linda Haynes completed an annual inspection of Koa Group Home. LPA met with House Manager (HM) Fernando Melendez who led a tour of the home. The facility was toured both inside and out with HM. Currently there are two clients in placement. The home is a one story building with four bedrooms and two an a half bathrooms. The Client's bedrooms were arranged so that no more than one client will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. There was a smoke detector in every bedroom. The four smoke detectors were checked, and they were working properly. There is one carbon monoxide detector in the home it is located in the kitchen. The carbon monoxide detector was checked and were working properly. The client's files are located in the office. There was a two day supply of perishable foods and a week of non-perishable foods. A trash can for storage of solid waste had a tight-fitting lid and was present. The sharp knives are in a locked cabinet in the kitchen. The medications are in a locked cabinet in the kitchen. The hot water in bathroom one (staff) measured to be 108.5 degrees Fahrenheit, in bathroom two was 106.7 degrees Fahrenheit and in bathroom three 108.6 degrees Fahrenheit. The home's First Aid kit was accessible and is located in office and contained all required supplies. The fire extinguisher was observed to be properly charged and inspected by the fire department. There are no firearms in the home as stated by the HM. There is no pool or other body of water at the home. The backyard where clients have access to play is fenced. . LPA reviewed two of two client files all required documents were present. LPA reviewed three of nine staff files all required documents were present. LPA interviewed one of nine staff members. A technical advisory will be issued for the front door that needs to be replaced. An exit interview was conducted and this report as well as LIC 811, technical advisory, and appeal rights was given to HM Fernando Melendez.


summary: Facility Evaluation

raw_content:
Narrative:
On November 15, Licensing Program Analyst (LPA) Linda Haynes met with Koa Staff to complete two additional interviews for a total of three out of nine staff.


summary: Facility Evaluation

raw_content:
Narrative:
On August 14, 2025 at 9: AM, Licensing Program Analyst (LPA) Raina Perez-Diaz completed an annual inspection of Koa Group Home. LPA met with House Manager (HM) Fernando Melendez who led a tour of the home. The facility was toured both inside and out with HM. Currently there are two clients in placement and one client is non-Verbal as confirmed by HM and the clients Needs and Services Plan. However, both were in school at the time of the inspection. The home is a one story building with four bedrooms and two an a half bathrooms. Bedroom #1 has one full size bed, and will sleep one client. Bedroom #2 has one full size bed, and will sleep one client. Bedroom #3 has one full size bed, and sleeps one client. Bedroom #4 has one full size bed, and sleeps one client. The Client's bedrooms were arranged so that no more than one client will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. There was a smoke detector in every bedroom and all smoke detectors were checked, and they were working properly. There is one carbon monoxide detector in the home it is located in the kitchen. The carbon monoxide detector was checked and working properly. The client's files are located in the office. There was a two day supply of perishable foods and a week of non-perishable foods. A trash can for storage of solid waste had a tight-fitting lid and was present. The sharp knives are in a locked cabinet in the kitchen. ***. The medications are locked in the staff office. The hot water was at a temperature of 124.0 degrees Fahrenheit and after adjustment, the water temperature measured at 122 which is still not in regulation; therefore, the facility is being cited for violation of California Code of Regulations (CCR) BUILDING AND GROUNDS Requirements 80088(e)(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water deliver to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F. The home's First Aid kit was accessible and is located in office and contained all required supplies. The fire extinguisher was observed to be properly charged and inspected by the fire department. There are no firearms in the home as stated by the HM. There is no pool or other body of water at the home. The backyard where clients have access to play is fenced. LPA Perez-Diaz reviewed files for two clients in care [Client #1 (C1) and Client #2 (C2)]. Clients' files were found to have Cash/Property/Valuables records, Medical Consent forms and signed needs and services plans. Based on interviews and record review it was determined C1 is currently 18 years old and is considered a Non-Minor Dependent (NMD); therefore, the facility is operating beyond the conditions and limitations specified on the license. The HM was advised and reported they were under the impression due to the client being placed in the home prior to their 18th birthday, C1 would not exceed the license limitations. HM indicated they are actively working on including NMD in their program statement and will provide an updated program statement and plan of operations to their assigned LPA; therefore, a Technical Violation (TV) was given. Review of the Administrative certificate for HM revealed it was currently pending. HM reported he has completed his training and passed the examination but has yet to have his background cleared. He provided email communication with the Care Provider Management Bureau (CPMB) working for a resolution. A copy of the completion certification for the training course and email with the examination results were sent to LPA. Therefore, the facility will be given a TV with the expectation the facility will provide a status update on August 28, 2025 via email. LPA also reviewed five staff files for [Staff #1 - Staff #5 (S1-S5)] and deficiencies were observed. Review of staff files (S1-S5) noted missing criminal record clearance for S1, S4, and S5. ***Continued on LIC- 809-C*** HM noted both staff have not been actively working at the facility for the last five months due to low enrollment and the administration are actively working on obtaining the clearances; therefore, the facility is being given a TV with the expectation the clearance or another status will be provided by August 28, 2025. Additionally, HM was informed the identified staff and any other staff without approved clearances will not be able to work at the facility until the clearance is obtained. HM understood. All staff files reviewed meet the training requirements per Community Care Licensing Regulations. Additionally, two staff were interviewed. Based on the facility inspection and file reviews on this date, one Type B violation, and three Technical Violations were issued to the facility. An exit interview was conducted and a copy of this report, the LIC 811, one LIC- 809-D, both LIC-9102 pages, and appeal rights was given to HM Fernando Melendez.

met_with: House Manager (HM) Fernando Melendez


summary: Facility Evaluation

raw_content:
Narrative:
On August 22, 2025 at 01: PM, Licensing Program Analyst (LPA) Raina Perez-Diaz arrived at Koa Group Home for the purpose of conducting a client interview for an annual inspection. LPA conducted one client interview. A copy of this report was reviewed and given to House Manager (HM) Fernando Melendez.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA), Val Wilson, on May 12, 2022 at 11: AM. During the inspection, LPA Wilson met with Samee Arastu, PsyD, Clinical Director/Administrator, and Fernando Melendez, House Manager, inspected the facility inside and out. During the tour of the facility, at 11:30AM, LPA Wilson observed the medication cabinet, medication bottles, medication storage cabinet, and the office holding medications were locked. LPA reviewed four of the four children's records on site at the facility at 12:30PM. During the review of children's records, LPA Wilson observed 4 out of 4 children did not have a separate log for each psychotropic medication prescribed with the date and time of each dose taken by the child. LPA reviewed 3 of the staff personnel files on site at the facility at 3:00PM. LPA interviewed 3 of the staff on site at 4:00PM. LPA attempted to interview 4 of 4 children currently taking psychotropic medication at 2: PM. Each child was unable to answer the questions due to cognitive ability and their interviews ended at question 3. LPA conducted exit interview with Michael Covarrubias, DSP, and by phone with Samee Arastu, at 4:49PM. LPA provided the Summary Report to Michael Covarrubia, DSP, upon completion. One deficiency was observed (refer to LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 5. Group Homes, Article 6. Continuing Requirements and Health & Safety Codes during the inspection.


raw_content:
Narrative:
Confidential witnesses provided consistent statements that staff did feed C1 and there was never a shortage of food at the facility. Confidential witnesses informed LPA that C1 was a picky eater and if it was not exactly what C1 wanted to eat then C1 would refuse to eat. LPA was informed that when C1 was first placed at the facility, C1 would mostly only eat junk food and refused to eat other more nutritious foods. Documentation received by LPA showed that C1 had not experienced weight loss while placed at the facility. CSW informed LPA that C1 was a picky eater but staff made accommodations for C1. LPA received other information that C1 was only provided with junk food at the facility and not adequately fed. Regarding the allegation that facility staff did not allow C1 to play video games, confidential witnesses stated that C1 and all clients were allowed to play video games and participate in all activities. LPA was informed that sometimes if safety concerns were present some clients may not be allowed to engage in activities away from the facility. CSW did not voice concerns regarding C1 not being allowed to participate in activities. LPA received other information that C1 was not allowed to play video games while at the facility. LPA received conflicting information regarding both allegations. Based on confidential interviews and record review the allegations staff does not provide adequate food service to C1 and staff does not allow C1 to partake in activities, may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Fernando Melendez.

Investigation Findings:
13On January 16, 2026, at 11: AM Licensing Program Analyst (LPA) Michael Almaraz met with Koa Home staff, Fernando Melendez, to issue the finding for the above allegations involving client (C1) listed on the confidential names list (LIC 811) dated January 16, 2026. The complaint was jointly conducted by LPA Almaraz and LPA Linda Haynes. On April 25, 2025, at 1: PM LPA Haynes conducted a safety inspection of the facility, and no immediate health and safety hazards were observed. Furthermore, LPA Haynes conducted one staff (HM) interview and one client (C1) interview. During the investigation LPA Almaraz interviewed one client (C3), one social worker (CSW), and three staff (S1, S2, S3). On April 18, 2025, the Department received a complaint alleging staff does not provide adequate food service to minor in care and staff does not allow minor to partake in activities. It was specially alleged that C1 was not being sufficiently fed, C1 was fed mostly junk food, and C1 was not allowed to play video games at the facility. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: KOA HOMEFACILITY NUMBER: VISIT DATE: 01/16/2026

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


facility_name: KOINONIA BHP - AUBURN

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Based on interviews conducted, it was reported that the youth was taken to the Emergency Room to be evaluated for a broken thumb on 9/12/22. Documents review also showed that youth was taken to the Emergency Room on 9/12/22. The youth was discharged from the facility on 9/19/22. Therefore, the facility was unable to complete a follow up appointment. Based on interviews, it was reported that the youth completed a follow up with the youth's new placement. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator . A copy of this report was provided to the agency.

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

met_with: Yaseem Sandoval, Administrator


summary: Complaint Investigation - Substantiated - 1 deficiency

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

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

Deficiencies:
40721: 1
2
3
4
5
6
7

complaint_status: SUBSTANTIATED

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

description:
1
2
3
4
5
6
7


raw_content:
Narrative:
the client was close to a table where they could have hit their head when resisting strenuously and the kitchen flooring made for an unstable surface as the chairs were sliding and the youth was able to get on the floor with their head close to the chair seat. The client also has a significant history of aggressive and impulsive behaviors that needed to be taken into consideration to prevent or minimize the potential need for restraining and this was this particular staff's first time working with the client. Additionally, the restraint started in the front yard where there are no cameras and conflicting versions of what happened were reported. Because general protocol was exercised and there is some discrepancy of what happened, the allegation is determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report and appeals process were provided.

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

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

met_with: HFT Director


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

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above agency on January 26, 2022 at 1: PM and met with Bill Ryland, Homes for Teens Director. The purpose of the inspection was to deliver complaint findings for the above allegation. On September 16, 2022 at 11: AM, Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility to initiate a complaint investigation related to the above allegation. LPA met with Diana Macneill, Interim Facility Administrator and Yasmeen Sandoval, Facility Administrator. LPA completed a physical inspection of the group home, inside and out. During the course of the investigation, the following documents were gathered and reviewed: Incident Reports for three youth, Police Reports regarding the 09/10/ Incidents involving FC1, and FC3; Resident Assessments for three youth, Face Sheets for two youth, Needs and Services Plans for four youth, Placement Referrals (Kaiser) for three youth, Client census log, Staff Roster and Schedules, Program Daily Schedule, Safety Plan for FC3, Emotional Regulation Action Plan for FC1 and FC4, and the Pre-Teen Behavioral Health Program Statement. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: KOINONIA BHP - AUBURNFACILITY NUMBER: VISIT DATE: 01/26/2023

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

met_with: Bill Ryland, Homes for Teens Director